Comparative study of sensitivity and specificity of Ultrasonography and Computed Tomography in clinically suspected acute appendicitis as a diagnostic tool and further correlation with histopathological examination

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COMPARATIVE STUDY OF SENSITIVITY AND SPECIFICITY OF ULTRA SONAGRAPHY AND COMPUTED TOMOGRAPHY IN CLINICALLY SUSPECTED ACUTE APPENDICITIS AS A DIAGNOSTIC TOOL AND FURTHER CORRELATION WITH

HPE"

Dissertation submitted to

THE TAMIL NADU DR.M.G.R. MEDICAL UNIVERSITY CHENNAI - 32, TAMIL NADU

With partial fulfilment of the regulations For the award of the degree of

M.S. DEGREE EXAMINATION BRANCH I – GENERAL SURGERY

COIMBATORE MEDICAL COLLEGE HOSPITAL COIMBATORE

APRIL 2016

DECLARATION BY THE CANDIDATE

I hereby declare that this dissertation titled "COMPARATIVE STUDY OF SENSITIVITY AND SPECIFICITY OF ULTRA

SONAGRAPHY AND COMPUTED TOMOGRAPHY IN

CLINICALLY SUSPECTED ACUTE APPENDICITIS AS A DIAGNOSTIC TOOL AND FURTHER CORRELATION WITH HPE" is a bonafide and genuine research work carried out by me under the guidance of Dr. S.SARADHA, M.S, F.I.C.S., FAIS., Professor of GENERAL SURGERY, Coimbatore Medical College and Hospital, Tamil Nadu, India.

DATE: Signature of the Candidate PLACE: Dr. CHANDRAMOHAN.D

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CERTIFICATE

"COMPARATIVE STUDY OF SENSITIVITY AND SPECIFICITY OF ULTRA SONAGRAPHY AND COMPUTED TOMOGRAPHY IN CLINICALLY SUSPECTED ACUTE APPENDICITIS AS A DIAGNOSTIC TOOL AND FURTHER CORRELATION WITH

HPE" Submitted by

Dr. CHANDRAMOHAN.D in partial fulfilment for the award of the degree of master of surgery in GENERAL SURGERY by The Tamil Nadu Dr .M.G.R. Medical University, Chennai, is a bonafide record of the work done by him in the Department of general surgery, Coimbatore Medical College and Hospital, during the academic year 2013-2016.

Guide & Professor Professor & HOD Department of general surgery Department of general surgery

Dean

Coimbatore Medical College Hospital Coimbatore

ACKNOWLEDGEMENT

I am extremely thankful to DEAN, Prof. Dr. A. EDWIN JOE M.D., Coimbatore Medical College and hospital, for his kind permission to carry out this study.

I am immensely grateful to Professor Dr. V. ELANGO, M.S, F.I.A.S., PROFESSOR and Head of Department of GENRAL SURGERY, Coimbatore Medical College and Hospital for his concern and support in conducting the study.

I wish to express my sincere gratitude and respect to Dr.S.Saradha, M.S, Professor of General Surgery, Without her active interest, constant and continuous guidance and direct supervision, this work would not have been possible. My gratitude to Dr.R.Radhika M.S, Dr.Umamaheshwari. M.S, Assistant Professors,Department of General Surgery, for their support and guidance.

I am thankful to all our General Surgery unit chiefs for their support in conducting the study.

I am thankful to all assistant professors for their guidance and help. I am thankful to all my colleagues for the help rendered in carrying out this dissertation.

I thank all the patients for their support in this study.

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ABSTRACT.

TOPIC.

Comparative study of sensitivity and specificity of Ultrasonography and Computed tomography in clinically suspected acute appendicitis as a diagnostic tool and further correlation with histopathological examination.

INTRODUCTION.

Acute appendicitis is one of the most common surgical emergencies in contemporary medicine. The diagnosis of acute appendicitis is essentially clinical. And advances in radiographic imaging have improved the diagnostic accuracy. This prospective study compared the sensitivity and specificity of Ultrasonography and Computed tomography in clinically suspected acute appendicitis as a diagnostic tool and further correlation with histopathological examination.

STUDY DESIGN.

One hundred and forty nine patients with clinically suspected acute appendicitis, followed the following protocol. Ultrasonography was done to all these patients. When ultrasonography failed to support the diagnosis, the patients were subjected to computed tomography. All the confirmed patients by imaging studies and the clinically suspected acute appendicitis patients were taken up for the surgery. The results of

ultrasonography and tomography were correlated with the histopathological examination and the follow up.

RESULTS.

The sensitivity, specificity, positive predictive value, negative predictive value and diagnostic accuracy for ultrasonography were 63%

,75% , 90% , 36% and 66% respectively.

The sensitivity, specificity, positive predictive value, negative predictive value and diagnostic accuracy for computed tomography were 91% ,92% , 95% , 85% and 91% respectively.

The sensitivity, specificity, positive predictive value, negative predictive value and diagnostic accuracy for combined ultrasonography and computed tomography ( in inconclusive ultrasonographic cases only) were 97% ,69% , 92% , 85% and 91% respectively.

CONCLUSION.

Computed tomography is better than ultrasonography in diagnosing acute appendicitis. Combined ultrasonography and computed tomography, only in ultrasonography inconclusive cases yielded a high diagnostic accuracy for acute appendicitis .It saved manpower, time ,cost and radiation.

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LIST OF CONTENTS

Sr.no. Title Page no.

1 INTRODUCTION 1

2. AIMS AND OBJECTIVES 3

3. REVIEW OF LITERATURE 4

4. MATERIALS AND METHODS 61

5. OBSERVATION AND RESULTS 79

6. DISCUSSION 86

7. CONCLUSION 88

8. ANNEXURE

BIBLIOGRAPHY PROFORMA MASTER CHART

TABLES LIST

Sr.no. Title Page

no.

1 Differential diagnosis for acute appendicitis 34

2 ALVARDO score 36

3 Implication of the total score (ALVARDO score) 37 4 Predicted number of patients with acute appendicitis 37 5 Appendicitis Inflammatory Response Score 38

6 Interpretation of the total score 38

7 Age, sex characteristics 79

8 USG findings 80

9 CT findings 81

10 H P E examination 82

11 Results 83

12 Post operative complications 85

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CHARTS LIST

Sr.No. Title Page

no.

1 Predicted number of patients with appendicitis (ALVARDO SCORE)

37

2 Age,Sexcharecteristics 79

3 USG findings 80

4 CT findings 81

5 H P E examination 82

6 Results 83

PICTURES LIST

Sr.No. Title Page

no.

1 Method to elicit Rebound tenderness 30

2 Method to elicit Rovsings sign 30

3 Method to elicit psoas sign 31

4 Method to elicit obturator sign 32

5 Method to elicit muscle guarding 33

6 Surgical team around the patient (laprascopy) 49

7 Various port positions 50

8 Picture of appendix,taenia coli and terminal ileum (laprascopy)

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9 Grid Iron incision 52

10 Lanz crease incision 53

11 USG machine 62

12 USG image of retrocaecal appendix 63

13 USG image of faecolith 64

14 USG image of non compressible,enlarged and distended appendix

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15 CT machine 66

16 CT work station 66

17 CT showing enlarged inflamed appendix 67

18 CT showing faecolith in appendix 67

19 Appendicectomy on progress (surgery ) 69

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20 Muscle splitting ( surgery) 69

21 Peritoneum opening (surgery) 70

22 Confluence of taenia coli traced 70

23 Appendix base ligation 71

ABBREVIATIONS

USG Ultra Sonogram

CT Computed tomography

HPE Histo pathological Examination

RIF Right iliac Fossa

P, + POSITIVE

N,- NEGATIVE

IC INCONCLUSIVE

RT RIGHT

LT LEFT

> GREATER THAN

< LESSER THAN

ASI Anterior Superior iliac Spine

LRI Lower Respiratory tract

Infection

SSI Surgical Site Infection

C/S Culture and Sensitivity

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INTRODUCTION

The vermiform appendix is considered by many as a vestigial organ. But now it is well recognized that the appendix is an immunologic organ. It secretes immunoglobulins, particularly immunoglobulin A.

When it gets inflamed it results in a clinical syndrome known as Acute appendicitis. Acute appendicitis is the most common cause of an acute abdomen in young adults. And Appendicectomy is the most frequently performed urgent abdominal operation. It is often the first major procedure performed by any surgeon.

Advances in radiographic imaging have improved the diagnostic accuracy. However the diagnosis of acute appendicitis is essentially clinical. It requires a mixture of observation, clinical acumen and surgical science. It remains as an enigmatic challenge and a reminder of the art of the surgical diagnosis. It is a subjective estimate of the probability of appendicitis based on multiple variables that individually are weak discriminators. Therefore when they are used in combination, they possess a high predictive value. But Appendicectomy based on clinical diagnosis alone leads to removal of a normal appendix in 15-30% of cases. The premise that its better to remove a normal appendix than to

delay diagnosis does not stand up to close scrutiny, particularly in the elderly.

Previous studies conflict whether the negative appendectomy rate can be decreased with the regular use of ultrasonography (USG) and computed tomography( CT).

Many authors have advocated the use of USG as a primary imaging modality. It is because of the radiation effects on this generally young patients.

So we wanted to compare USG and CT in acute appendicitis. At the same time we wanted to reduce radiation and cost. So CT was taken only when USG was inconclusive and this pathways effectiveness was also assessed.

We designed a prospective study to compare the sensitivity and specificity of USG and CT in clinically suspected acute appendicitis as a diagnostic tool and further correlation with the histopathological examination. Here CT was done only when the USG was inconclusive.

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OBJECTIVE

1. To determine sensitivity and specificity of USG in clinically suspected acute appendicitis as a diagnostic tool and further correlation with HPE.

2. To determine sensitivity and specificity of CT in clinically suspected acute appendicitis as a diagnostic tool and further correlation with HPE.

3. Compare USG and CT in clinically suspected acute appendicitis as a diagnostic tool and further correlation with HPE.

REVIEW OF LITERATURE

HISTORY

Appendiceal disease is a frequent cause for the emergency hospital admission. Appendicectomy is one of the most common emergency surgical procedure performed. The appendix plays a prevalent role in the health care today, but the human appendix was not noted until 1492.

Leonardo da vinci.

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Vesalius drawing.

Although sketched in the anatomic notebooks of Leonardo da vinci , the appendix was not formally described until 1524 by da Capri and 1543 by Vesalius.

Jean Fernel.

The first description of a case of appendicitis was by Jean Fernel in 1554.A 7 yr old girl with diarrhea was treated with a large doses of quince, an apple – like fruit used in folk remedies. But later she developed complications of acute appendicitis and died.The Autopsy showed obstructed appendix lumen. It also revealed necrosis and perforation.

Lorenz Heister gave the first description of classic appendicitis in 1711.

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Claudius Amyand.

The credit for performing the first appendicectomy goes to Claudius Amyand. He was a surgeon at st.george s hospital in London.

He was the sergeant surgeon to Queen Ann,King George I and King George II. In 1736, he operated on an 11 year old boy with a scrotal hernia and a fecal fistula. Within the hernia sac ,he found the appendix which was perforated by a pin. The patient got discharged with no serious complications.

The Appendix was not identified as an organ capable of causing disease until the 19^th century.

In 1824, Louyer - villermay presented a paper in the Royal Academy of Medicine in Paris. His paper was about the two autopsy cases of appendicitis. He emphasized the importance of the acute appendicitis.

In 1827, Francois Melier, a French physician, expounded on Louyer - Villermay s work. He reported 6 autopsy cases. He was the first to suggest the antemortem recognition of appendicitis. This work was discounted by many physicians of the era, including Baron Guillaume Dupuytren.

Dupuytren.

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Dupuytren believed that inflammation of the caecum was the main cause of the pain in the right lower quadrant. The term typhlitis or peri- typhlitis is used to describe right lower quadrant inflammation.

In 1839, a textbook authored by Bright and Addison entitled Elements of Practical Medicine was released. It contained detail explanation about the symptoms of appendicitis. Appendicitis was identified as the primary cause of inflammatory processes of the right lower quadrant.

Reginald H. Fitz, was a professor of pathologic anatomy at Harvard. He is credited with coining the term appendicitis. His paper identified the appendix as the primary cause of right lower quadrant inflammation. He also recommended consideration for operative treatment for acute appendicitis.

Initial surgical therapy for appendicitis was to drain the right lower quadrant abscess. It occurred secondary to appendiceal perforation.

It appears that the first surgical management for appendicitis without abscess was by Hancock in 1848. He incised the peritoneum and drained the right lower quadrant. But he did not remove the appendix.

The first published account of appendicectomy for appendicitis was by Kronlein in 1886. But this patient died 2 days after the operation due to post operative complications.

Thomas Morton was first to diagnose appendicitis, drain the abscess and remove the appendix with recovery. He published his findings in 1887.

Fergus in Canada performed the first elective appendicectomy in 1883.

Charles Mcburney.

The greatest contributor to the development in the treatment of appendicitis was Charles Mcburney. He published a paper in the New York State Medical Journal in1889. It describes the indications for early laparotomy in the treatment of appendicitis. In this paper he describes the McBurney point as follows “ maximum tenderness, when one examines

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with the finger tips is , in adult, one half to two inches inside the right anterior spinous process of the ilium on a line drawn to the umbilicus. He published another paper in 1894.It describes the incision which bears his name. But McBurney later credited McArthur with first describing this incision.

Sir Frederick Treves.

In 1890s,Sir Frederick Treves of London Hospital advised conservative management for the acute appendicitis. And later followed by appendectomy after the infection has subsided. But unfortunately he could not save his youngest daughter who developed appendicitis.

In 1982 Kurt Semm was credited for performing the first successful laproscopic appendicectomy.

Appendicitis of King Edward VII--

In 1902 two days before his scheduled coronation, the king of England, Edward VII developed a ruptured appendix. He underwent surgery. This radically changed the world’s perception of appendicitis and appendectomy.

Surgeon Removes Own Appendix

A Russian Surgeon who was isolated in Antarctica successfully removed his own appendix,in 1961.

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The problem was to identify early the patients who had the progressive , often lethal form of the disease. So early appendicectomy became the standard of care.

Appendicitis is a disease of the young. The 40% of cases occurs in patients between the ages of 10 and 29 years. Appendicectomy is the most commonly performed emergency operation in the world. The surgical treatment of appendicitis has advanced in the last 150 years.

Currently , the mortality rate for acute appendicitis is reported to be less than 1%.

But this had no impact on the incidence of perforated appendicitis.

It was also later recognized that most cases of appendicitis resolves without surgical treatment. And the negative effects of large number of appendicectomies of uninflamed appendices were noted.

Therefore the focus is also on the conservative management.

Anatomy

External marking for the Base of Appendix.

The vermiform appendix is present only in humans, certain anthropoid apes and the wombat.

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The picture depicting the Openings of Appendix & Ileum in caecum.

 Appendix is a blind muscular tube. Its base is on the caecum at the confluence of the three taeniae coli.

 In adults the average length of the appendix is 6 to 9 cm.Its length varies from less than 1 cm to greater than 30 cm.

 The outer diameter varies between 3 to 8 mm.Where as the luminal diameter varies from 1 to 3 mm.

 The lumen is quite small. It may be partially or completely obliterated after mid-adult life. The luminal capacity of the normal appendix is only 0.1 ml.

EMBRYOLOGY.

Morphologically it is the undeveloped distal end of caecum.

 In the 6^th week of embryonic life the appendix and caecum appear as outpouchings from the caudal end of the midgut. Then it begins to elongate. At about the 20^th week it achieves a vermiform appearance.

 At birth the appendix is short. And its opening is broad in the caecum. As the age increases appendix lengthens, but the opening size decreases.

 During the growth, the caecum commonly rotates the appendix into a retrocaecal but intraperitoneal position. It is due to the unequal growth of the lateral wall of caecum. In one quarter of cases rotation does not occur.

The various positions of the appendix.

Occasionally, the tip of the appendix becomes extraperitoneal. And it lies behind the caecum or ascending colon.

 Rarely the caecum does not migrate during development to its normal position in the right lower quadrant.

 But the position of the base appendix is constant.

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MESENTRY.

The mesentery of appendix arises from lower surface of the mesentery or terminal ileum.

In children mesoappendix is transparent. As the age advances it becomes laden with fat.

There are variations. Sometimes distal one third of the appendix is bereft of mesoappendix.

Mesoappendix displayed demonstrating the appendicular artery.

BLOOD SUPPLY.

The appendicular artery is an end artery.

 Arterial supply: It is a branch of the lower division of the ileocolic artery. It passes behind the terminal ileum to enter the mesoappendix, close to the base of appendix.



mesenteric veins. And they drain into the portal vein.

Superior mesenteric artery

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Anatomical relations for the caecum

LYMPHATICS.

 Six or more lymphatic channels traverse the mesoappendix which empty into ileocaecal lymph nodes.

 Few of the lymphatics pass through the appendicular nodes which are situated in the mesoappendix.

NERVE SUPPLY.

 Sympathetic elements is supplied by the superior mesenteric plexus(T10-L1).

 And the afferents are from the parasympathetic elements via the vagus nerves.

HISTIOLOGY.

LAYERS OF THE APPENDIX WALL.

1. Mucosa

2. Muscularas mucosa (ill defined) 3. Sub Mucosa

4. Muscularis externa (thin) comprising of two layers, outermost is the serous layer.

THE DIAGRAM OF APPENDIX HISTIOLOGY.

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Microscopic Picture of Normal Vermiform appendix

 The lumen is very narrow . And there are no villi.

 The lumen is irregular being encroached upon by multiple longitudinal folds of mucous membrane They are lined by columnar cells of colonic type. Few crypts are present. They are irregularly sized and shaped. In colon they are uniform. The base of crypts contains argentaffin cells. Neural fibres, neurosecretory cells are positioned just below the crypts.

 The mucosa is bounded by a relatively thin muscularismucosa.

There is usually abundant lymphoid tissue in the submucosa, especially in younger individuals. That is why it is called as abdominal tonsil.

 The outer Muscularis externa comprises of two layers. The outermost is the serous layer.

PHYSIOLOGY.

 Appendix is an immunologic organ. It actively participates in the secretion of immunoglobulins, particularly immunoglobulin A.

There is no clear role for the appendix in the development of human disease. But an inverse association is noted between appendicectomy and the development of ulcerative colitis. This association is seen only before 20 years of age.

A recent meta analysis demonstrated a significant risk of crohns disease following early appendicitis. The risk diminishes later.

 Appendix may function as a reservoir. It may recolonize the colon with healthy bacteria.

EPIDEMIOLOGY.

 The Acute Appendicitis has a yearly incidence rate of about 100/100,000, population.

 The lifetime risk of developing appendicitis is 8.6% for males and 6.7% for females.

The highest incidence in second and third decades.

 The incidence rate of appendicectomy is decreasing. But there is an increase in the incidence rate of non perforated appendicitis. It is due to the development in diagnostic imaging.

.

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 The prevalence of malignancy in appendicectomy remains at or below 1%.

Etiology of Acute Appendicitis.

Appendicitis is common because of:

1. The presence of lymphatic follicles in submucosa.

2. Appendicular artery is an end artery.

3. As lumen is small it gets obstructed .,example by faecolith.

4. Gaps in the thin muscular externa cause fast spread of infection.

5. Low fibre diet.

PATHOLOGY

Flow chart for pathogenesis.

The pathology is due to the following:

1.OBSTRUCTION 1.Inflammation resolves

2.INFECTION 2. Mass formation.

3.Lymphatic obstruction 3. Perforation . 4.Venus obstruction 4. Abscess

5. Ischaemia 5. Diffuse Peritonitis

6.Mucocoele 6.portalpyaemia.

7.intestinal obstruction.

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MICROBIOLOGY.

The flora of the inflamed appendix differs from that of the normal appendix.

In acute appendicitis there are 1.More anaerobes.

2.Tissue contain Escherichia coli and bacteroids.

3.Fusobacterium nucleatum/necrophorum.

4.Fastidiuos gram negative anaerobic bacilli.

NATURAL HISTORY.

 Pathogenesis is not completely understood.

 It has been proposed that perforation and non perforated appendicitis may be are different diseases. It is based on the epidemiological studies.

CLINICAL DIAGNOSIS.

SYMPTOMS.

 The chief complaint is pain.

The patients may complain a sensation of obstipation prior to the pain.

And they may feel that defecation will relieve the pain.

Classic pain sequence we get here is:

1. FIRST Periumbilical colic pain (visceral peritoneum)

2. SECOND Pain shifting to right iliac fossa(parietal peritoneum)

The Sequence of symptoms in the order are 1.Anorexia

2.Abdominal pain.

3.Vomiting.

Murphy's Syndrome, in order of appearance, are 1. Pain

2. Vomiting 3. Temperature

The symptoms vary with the position of the appendix.

PAIN.

Time of onset.

 Pain in acute appendicitis starts early in the morning.

 In case of duodenal perforation it is in the post lunch period.

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Mode of onset.

 In acute appendicitis the pain is boring in the beginning. Suddenly it becomes acute in case of obstruction. This waken up the patient.

 It can be precipated by the use of purgatives.

How long.

Appearing on and off for the last few years is the feature of appendicitis, cholecystitis.

Site of pain.

Right iliac fossa.

Pointing test with one finger.

If the pain is diffuse he will use his whole hand.

Shifting pain.

Initially pain is around umbilicus (visceral) later it shifts to the RIF(parietal).

Radiation.

 In spreading peritonitis the pain is first in the region of the affected organ. But it soon spreads all over the abdomen.

 When the appendicitis patient complains of a radiating pain towards the left iliac fossa the condition is one of the spreading peritonitis.

 In duodenal perforation (APD) pain is felt first at right hypochondrium. But soon it radiates to RIF as gastric contents

gravitate down the right paracolic gutter.This mimics acute appendicitis.(Valentino’s appendicitis)

Referred pain.

In affection of ileum and appendix, the pain is around umbilicus(T9,T10).

Characters of pain.

Colicky in obstruction.

Constant burning pain in peritonitis.

Severe agonizing pain in acute pancreatitis,torsion.

Throbbing in acute infalammation.

Change in the character of pain.

Colicky pain to constant burning type pain,think of strangulation.

Dimunition of pain,think of perforation.

In 2^nd stage of peritonitis,pain decreases because of the dilution of the gastric contents with peritoneal exudates.

Vomiting.

Frequency & quantity.

 In acute appendicitis vomiting may or may not be present.

 In acute appendicitis nausea is more often complained.

Nausea and vomiting are characteristic complaints of pre/post ileal appendicitis.

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Character and the vomitus.

Projectile in toxic enteritis and high intestinal obstruction.

Quiet regurgitant in general peritonitis.

In late case of peritonitis, gastrocolic fistula, intestinal obstruction and in uraemia the vomitus is dark brown faeculent mixed with altered blood.

Relationship with the pain.

Pain precedes vomiting in acute appendicitis, acute pancreatitis, peptic ulcer and renal colic.

CLINICAL SIGNS

Patient should lie flat on his back with legs extended.

Whole abdomen from nipples to saphenous openings are exposed Examination is carried out in good light.

 Pyrexia(temperature elevation is rarely >1*C / 1.8* F., pulse rate is normal or elevated. Greater magnitude usually indicate that a complication has occurred. Or that another diagnosis should be considered.)

Temperature is a late sign

 Localized tenderness in the right iliac fossa.

 Rebound tenderness.

Picture depicting method to elicit rebound tenderness

 Deep palpation of the left iliac fossa may cause pain in the right side (Rovsing sign).

Method to elicit Rovsing sign

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 Cutaneous hyperesthesia in the area supplied by right spinal nerves at T10,T11,T12.

 If it lies on Psoas. On extension of the hip,the pain increases (psoas sign).

Method to elicit psoas sign

 If it lies on obturator internus. Flexion and internal rotation of hip increases the pain(obturator sign).

Method to elicit obturator sign

 With retrocecal appendix, the anterior abdominal findings are less striking. And tenderness is more marked in the flanks.

 In a inflamed appendix hanging into pelvis, rectal examination reveals pain in pouch of Douglas.

 Early in the disease , there is voluntary guarding of abdominal wall muscles. Later it is largely involuntary due to contraction of muscles. It is due to the inflamed parietal peritoneum beneath.

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Method to elicit muscle guarding

The lower hand feels, upper hand gives pressure

Differential diagnosis are:

Children Adult Adult Female Elderly

Gastroenteritis Regional enteritis

Mittelschmerz Diverticulitis

Mesenteric adenitis

Ureteric colic Pelvic inflammatory disease

Intestinal Obstruction Meckel’s

diverticulitis

Perforated peptic ulcer

Pyelonephritis Colonic carcinoma Intussusception Torsion of testis

in Male

Ectopic pregnancy Torsion appendix epiploicae

Henoch- Schonlein purpura

Pancreatitis Torsion/rupture of ovarian cyst

Mesenteric infarction

Lobar pneumonia Rectus sheath haematoma.

Endometriosis Leaking aortic aneurysm

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Rare differential diagnosis.

1.Herpetic pain of right 10^th and 11^th dorsal nerves.

2.tabetic crisis.

3.Tuberculosis, malignancy involving vertebra.

4.Porphyria and diabetes mellitus.

5.leukaemic ileocaecal syndrome.

Investigations

Laboratory findings.

 Mild leukocytosis ranging from 10,000 to 18,000 cells/mm³. Raised levels raise the possibility of a perforated appendix with or without an abscess.

 Several white or red blood cells can be present from ureteral or bladder irritation.

Bacteriuria in a urine specimen obtained via catheter generally is not seen in acute appendicitis.

Clinical scoring systems.

For diagnosing acute appendicitis we have to combine signs,symptoms and investigations. It is because each variable are individually weak in diagnosing acute appendicitis.

The ALVARDO score is most widely used.It is useful in ruling out appendicitis.

The Appendicitis Inflammatory Response Score resembles the ALVARDO score.It includes C R P.It is more accurate than ALVARDO scoring system.

ALVARDO SCORING SYSTEM.

SYMPTOMS

M

A

N

T

R

E

LABORATORY.

L

S

Total 10

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IMPLICATION OF THE TOTAL SCORE

Score greater or equal to 7 High likelihood of appendicitis

Score 4 to 6 consider further imaging

Score less than 3 Low likelihood of appendicitis

Predicted number of patients with appendicitis.

Alvardo score 1 to 4 30%

Alvardo score 5 to 6 66%

Alvardo score 7 to 10 93%

Predicted number of patients with appendicitis according to alvardo score

Appendicitis Inflammatory Response Scoring system.

Vomiting 1

Pain RIF 1

Rebound tenderness/muscle rigidity Light 1

Medium 2

Strong 3

Temperature 1

Polymorpholeukocytes 70-84% 1

>84% 2

WBC count cells / L upto 14.9x10⁹ 1

Above 15 x10⁹ 2 C – reactive protein concentration 10 – 49 g/L 1

49 g/L 2

Interpretation.

9-12 High probability surgical exploration needed 5-8 indeterminate observation/ diagnostic laproscopy

0-4 Low probability follow-up

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RADIOGRAPHY.

 X rays emitted from an source are absorbed to varying degrees by substances. The absorption depends on density and atomic number of the substance. Higher the density, greater reduction in the number of photons. Less photons cause less amount of blackening in the film.

 There is a lack of soft tissue contrast due to similar quantities of water. To obviate this problem, Contrast material is administered.

 Fluoroscopy allows real time monitoring of organs.

1. Plain x-ray abdomen.

 Fecalith if present, is highly suggestive of acute appendicitis.

 An abnormal bowel gas pattern., which is nonspecific.

 And to rule out other causes of acute abdomen.

2. plain x-ray chest.



A.



B



C.



D.



E.

 If appendix fills, an appendicitis is excluded.

 If it does not fill, no determination can be made.

4.radioactively labeled leukocyte scans.

 Costly

 Rarity

 Only few studies available

ULTRA SONOGRAPHY.

 Here the high frequency sound waves are generated by a transducer containing piezoelectric material. The generated sound waves are reflected by tissue interfaces.

 By determining the time taken for the pulse to return and the direction of the pulse, the image is formed. Medical ultrasound uses frequencies of the range between 3 to 20 MHz.

 Abdominal transducers use frequency between 3 to 7MHz.The higher the frequency, greater the resolution. But less the depth.

 Doppler ultrasound also uses waves reflected by moving red blood cells.

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 The use of panoramic or extended field of view ultrasound provides images that are easily interpreted.

 The Advantages are : 1. there is no radiation.

2. not expensive.

3. interaction with the patients, possible.

4.Good soft tissue resolution in the near field.

5.Dynamic studies can be performed.

6.high frequency sound waves are used for the soft tissues.

7.Excellent for cysts.

8.Doppler studies assess the blood flow.

9.It is used as a guide in interventional biopsies and drainages.

 The Disadvantages are :

1.Interpretation only possible during the scan.

2.Long learning curve .

3.Resolution is dependent on the machine available.

4.Images cannot be reliably reviewed away from the patient.

5.Ultrasound wave is attenuated by air and bone.

INTERPRETATION

 The normal appendix is identified as a blind ending, non peristaltic bowel loop originating from the cecum. It is easily compressible, measuring lesser than or equal to 5mm in diameter.

 In acute appendicitis it is non compressible. It is greater or equal to 6mm in the anteroposterior direction.

 An appendicolith with distal distention establishes the diagnosis.

 Thickening of the appendiceal wall and the presence of periappendiceal fluid is highly suggestive of acute appendicitis.

 If normal appendix is visualized, it is marked as negative or – or N.

 If it is not visualized, it is marked as inconclusive or IC.

 False positive scan are due to:

1.Periappendicitis from surrounding inflammation.

2.Dilated fallopian tube.

3.Inspissated stool.

4. In Obese, appendix may not be compressible because of the fat.

 False negative scan are due to:

1.Appendicitis confined to tip of appendix.

2.Retrocecal appendix.

3.Markedly enlarged appendix , mistaken for small bowel.

4.Perforated appendix, therefore compressible.

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COMPUTED TOMOGRAPHY.

 There has been a lot of development in CT technology in the past 30 years from the initial conventional CT scanners through to helical / spiral scanners.

 CT scanner consists of a gantry containing the x ray tube, filters and detectors which revolve around the patient. This information is mathematically reconstructed to produce a two dimensional grey scale image of a slice through the body.

 Modern scanners allow for the continuous movement of the table and the patient during gantry revolution. So this reduces the scan time.

 With contrast usage the scan can be done at different phases of enhancement. It is advantageous in identifying different diseases.

 The thinner collimation and improved spatial resolution have resulted in newer techniques. Now a three dimensional images can be reconstructed.

Radiation effects.

 CT scan of the abdomen and pelvis gives a radiation dose equal to taking 500 chest radiographs.

 It is equal to 10 mSv.It is equalent to getting 4.5 years of natural background radiation.

The effects of radiation are divided into two groups.

1. Dose dependent tissue effects., example is cataract.

2. All or nothing effects(stochastic)., example is cancer.

 Radiation and cancer.

 The lifetime risk of cancer for people is about 1:3.

 The risk of radiation induced cancer for x rays are in the order of 1:1000000.

 In case of CT risk of cancer increases to the order of 1:1000.

 The Advantages of CT are :

1. good spatial and contrast resolution.

2. Contrast resolution can be increased with imaging in arterial and or venous phases.

3. Rapid images in one breath hold.

4. Allows global assessment of the abdomen and pelvis.

5. Three dimensional imaging is possible.

6. Obese persons.

7. Elderly patients.

8. Immuno compromised individuals.

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 The Disadvantages of CT are:

1. High radiation dose.

2. Poor soft tissue resolution of the peripheries and superficial structures.

3. Patient need to be able to lie flat and still.

4. cost.

5. contrast can give rise to allergic reactions. It is nephrotoxic.

INTERPRETATION

 Inflamed appendix appears dilated(>5cm).

 The walls are thickened.

 Dirty fat, thickened mesoappendix and even an obvious phlegmon.

 Fecaliths with distal dilated lumen.

 Arrowhead sign, caused by thickening of cecum andfunnelling contrast agent at the orifice of inflamed appendix.

 If normal appendix is visualized, it is marked as negative or – or N.

 If appendix is not visualized, it is marked as inconclusive / IC.

 False positive scan can be due to:

A fluid filled normal small bowel loop.(so the importance of oral contrast)

 False negative scan can be due to:

1. Distal appendicitis.(so trace appendix from base to tip) 2. Paucity of intraabdominal fat.(use oral or rectal contrast) 3. Small bowel dilatation or abscess formation.

4. Early in the course of appendicitis.(repeat computed tomography after 24 hours)

MAGNETIC RESONANCE IMAGING

 MRI depends on the fact that nuclei containing an odd number of protons or electrons have a characteristic motion in the magnetic field(precession). And this produces a magnetic moment.

 In a strong uniform magnetic field(MRI) these nuclei align themselves with the main magnetic field. This results in a net magnetic moment.

 A brief radiofrequency pulse is then applied to alter the motion of the nuclei. Once the pulse is removed, nuclei realign themselves with the magnetic field(relaxation).In this process it emits a radiofrequency signal which is recorded.

 Relaxation is measured in two ways.,T1,T2 .

 Fat, methaemoglobulin and mucinous fluid are bright in T1 weighted images. It highlights the anatomy.

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 T2 are bright according to the increase in water content. It highlights the pathology.

 The Advantages are:

1. No radiation.

2. Excellent soft tissue contrast.

3. Children 4. Pregnancy

 The Disadvantages are:

1. Contraindicated in patients with metallic bodies, pacemakers, cochlearimplants, cranial aneurysm clips.

2. Relative contraindication in first trimester pregnancy, and claustrophobia.

3. Long scaning time.

4. Rare availability.

5. Costly

RADIOACTIVELY LABELED LEUKOCYTE SCAN.

 A radionuclide is administered as a part of a radiopharmaceutical agent. Gamma camera is used to detect the emission.

 Commonly used radionuclide are technetium, gallium, thallium, iodine. It is coupled with the compounds that is taken up by tissues of interest.

The Advantages are :

1. Allows functional imaging.

2. Allows imaging of the whole body.

3. Valuable in occult infection and inflammatory bowel disease.

4. It detects metastatic cancer.

The Disadvantages are :

1. Specific agent is required for specific indication.

2. Abnormal result may require further imaging.

3. Poor spatial resolution.

 LAPAROSCOPY

Both diagnostic and therapeutic.

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TREATMENT

Early operative intervention is the treatment of the choice.

The available methods are : 1. Open appendicectomy.

2. Laproscopic appendicectomy.

The Surgical Team around the patient

Various Port placements

Picture showing appendix, taenia coli and ileum.

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3. N.O.T.E.S:

Natural orifice transluminal endoscopic surgery.(example transvaginal removal of appendix and transgastric).

Open Appendicectomy Approaches are

1. Grid iron incision 2. Lanz creaze incision

3. Rutherford morrison's lateral muscle cutting incision 4. Fowler weir approach by cutting lateral part of the rectus 5. Lower midline incision

6. Right lower paramedian incision

Grid Iron Incision

 It is a frame of cross beams to support the ship during repairs

 It was first described by MC arthur

 Incision is made perpendicular to a line joining right anterior superior iliac spine to the umblicus, centering the Mc burney's point

 In pregnancy appendix base is within 2cm of the Mcburney's point

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Lanz creaze Incision

 More Popular

 Transverse skin crease incision

 Exposure is better

 Incision is approximately 2cm below the umbilicus centering on the line formed by mid clavicular point and mid inguinal point

 Lower Mid Line Incision

 It is used when the diagnosis is in doubt

 In presence of intestinal obstruction

 It is better than right paramedian incision. It is easy to extend. It has a good access to pelvis and peritoneal cavity

Management of App Stump

 absorbable 2/0 or 3/0 is used to put purse string or Z suture. It may

be inserted into caecum about 1.25cm from the appendix base.

 It should pass through the muscle coat, picking up the taeniae coli.

 Many surgeons believe invagination is unnecessary.

1. No crushing, 1. 2 stitches are placed Ligation tight through caecil wall

enough to occlude close to the base.

the lumen and appendix 2. appendix flush amputated amputation done 2. Invagination stitches tied

3. 2^nd layer of interrupted sero muscular sutures

made

Management of the base of appendix

Caecial Wall Edema

Base of appendix

inflamed

Base of appendix Gangrenous

Edema Limited

Edema Extensive

Purse string suture using healthy caecal wall No Invagination

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PROBLEMS ENCOUNTERED DURING APPENDICECTOMY

Normal Appendix

Appendix not found

Tumour

Abscess

Mass

Crohn's Disease

1. Exclude terminal Ileitis, Meckels diverticulitis, tubal cause, Ovarian cause.

2. 1/4^th normal looking appendix show inflammation in HPE.

1. Caecum mobilized

2. Confluence of teaniae coli traced

1. Less than 2cm size – appendicectomy 2. greater than 2cm size- right

hemicolectomy

Appendix Found totally necrotic – right hemicolectomy

Appendix not able to be removed – drain.

Interval appendicectomy

Healthy base- appendicectomy Caecal Wall not healthy - drain

Drain

For Both complicated and uncomplicated appendicitis keeping drain has not been supported in clinical trials

Irrigation

Not recommended Skin

Can be closed primarily in patient with perforation INCIDENTIAL APPENDICTOMY

 It is the removal of normal appendix at laprotomy for other conditions

 Done in recurrent vague lower abdomen pain of doubtful severity

 Done along with ladd's procedure for mal rotation

 It is also done during on table colonic lavage

POST OPERATIVE COMPLICATIONS

 Reactionary haemorrhage

 Wound Infection

 Intra abdominal Abscess

 Ileus

 Lower Respiratory tract Infection

 deep vein thrombosis.

 pylephlebitis.

 faecal fistula.

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 FAECAL FISTULLA MANAGEMENT.

 usually conservative management( low output)

 investicate for distal obstruction.

 if persists even after 6 weeks, consider resection , anastomosis

MUCOCELE OF APPENDIX

Non – Neoplastic Non – Neoplastic

Retension cyst

Subacute appendicitis

Empyema

Rupture

Localized pseudomyxoma

Peritonei

Appendicectomy

Rupture

Generalized pseudomyxoma

Peritonei

Surgical debulking +

Neoplasms of Appendix 1. Carcinoid

2. Adenocarcinoma 3. Mucocele

4. Lymphoma Special Circumstances Young

1. Under developed Greater omentum 2. More rapid progression

3. History and Examination difficult Elderly

1. Expanded differential diagnosis 2. Communication Difficulty Pregnancy

1. Most common surgical emergency in pregnancy 2. Laboratory evaluation not helpful

3. Appendicectomy even if it is a normal appendix, carries a chance of fetal loss and risk of early delivery

Stump Appendicitis

1. Appendix base should not be longer than 0.5cm 2. Under reported

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Immuno suppressed

1. Incidence rate higher 2. Relative Leukocytosis 3. Delayed Presentation

4. Opportunistic infection should be considered 5. Neutropenic enterocolitis

TREATMENT FOR APPENDICEAL ABSCESS.

1. PHLEGMONS AND SMALL ABSCESS

conservative management with IV antibiotics.

2. WELL LOCALIZED ABSCESS percutaneous drainage.

3. COMPLEX ABSCESS surgical drainage.

If operative drainage is required it should be performed using an extraperitoneal approach, with appendicectomy reserved for cases in which the appendix is easily accessible.

4. MASS FORMATION.

Interval appendicectomy is performed atleast 6 weeks after the acute event, for all the patients treated either non operatively or with simple drainage of an abscess.

The aim of the OCHSNERSHERREN REGIMEN is to treat infection. Relieve pain . Supplement the fluids and electrolytes over a period of 48 to 72 hours.

CRITERIA TO STOP CONSERVATIVE MANAGEMENT:

a. Rising pulse rate.

b. Increasing or spreading abdominal pain.

c. Increasing size of the mass or no decrease in the size of the mass.

PROGNOSIS.

In acute appendicitis the Mortality rates are coming down. Death is attributable to uncontrolled sepsis. Morbidity rates parallel mortality rates. It is increased by the rupture of appendix.

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MATERIALS AND METHODS

The study was approved by the hospital’s ethical committee for human studies. All patients of 13 years and above who presented to the Surgery department with symptoms of acute appendicitis were included in this study.

All patients were evaluated. Patients with typical signs of acute appendicitis with the ALVARDO score 7 and above were included in the study. Patients who had developed signs and symptoms of acute appendicitis during their clinical observation were also included.

The radiologic procedures and logistics of the study were explained to the patients, and informed consent was obtained from each patient. If other pathology was suspected, patients were referred to other specialists, as necessary.

Between August 2014 and August 2015, 469 patients presented to our surgery department with acute pain in the right lower abdomen. The patients age, sex, ALVARDO score, USG report, CT report, surgical findings and HPE report are noted.

Out of 469 patients with 13 years of age and above with RIF pain , 149 were selected based on the ALVARDO score 7 and above. And the

patients who gave acceptance to undergo the study after making the patient understand his health condition, the treatment options available and it related complications.

All the selected 149 patients underwent imaging studies with ultrasonagram. They were paired into two groups. The First Group Contains visualizing the inflamed appendix. And it is marked as positive ( + ) / P.

Ultra sound (Sonoscape SS1-5000) with 3.5 & 5 Mhz convex

& 7.5 Mhz linear array

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The asterisk indicates the inflamed fat The dotted line

indicates enlarged retrocecal appendix

USG Showing Faecolith

The other group contains both the patients in whom the normal appendix is visualized ,it is marked as negative ( - ) / N and in the patients in whom the appendix is not visuialized ,it is marked as inconclusive ( IC)

Out of 149 patients scanned with USG,82 were positive. Out of 82 cases Four had mass formation. But they were taken up for interval appendicectomy.

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Image shows non compressible, enlarged, distended appendix

52 were inconclusive and 15 had alternate diagnosis on scanning., totalling to 67.Complimentary CT scan was done to this group.

CT machine(Toshiba 4 slice Alexion)

Work Station

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Perappendicular fat standing shown by the asterisk and appendix is 13 mm enlarged.

Image of faecolith in CT

Scanning was performed with the following parameters : 1 second per rotation time ,1.5 mm collimation,& 32 mm/sec table increment (pitch,1.33)

.All patients received intravenous contrast material (100-120 ml iodixanol,320 mg iodine per milliliter),injected at a rate of 3-4 ml per second with a scanning delay of 70 seconds.Transverse sections were reconstructed with a 5 mm thickness at 2.5 mm intervals.

The results of the CT scan are also grouped into two.The first group which had the inflamed appendix is marked as positive (+ ).The other group contains both the patients where the normal appendix is visualized,marked as negative ( - )/N and where the appendix not visualized, marked as inconclusive (IC).

Out of 67 cases containing USG negative and inconclusive groups, 41 cases are positive for CT, 11 Cases of negative and inconclusive patients. And 15 cases had alternate diagnosis.

The positive cases in USG, CT groups and the clinically suspected cases of acute appendicitis in CT inconclusive were taken up for the surgery. So totally 82 (USG +) + 41 (CT +) + 11 (CT inconclusive but clinically acute appendicitis), 134 cases were taken up for the surgery.

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Open Appendicectomy on progress

Muscle splitting

Peritonium Opened

Confluence of taenia coli traced

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Appendix delivered

Appendix Base ligated after skeletonizing the appendix

At surgery macroscopic findings were noted. And the inflamed appendix is marked as positive (+), the normal looking appendix were marked as negative (-).

At surgery out of 134 cases, 124 cases were positive/+/P. Two had gangreneous appendicitis, Seven had perforation, ten cases had faecolith ( 2 gangrene + 7 perforation + 1 inflammed appendix),Two cases had mass formation and Ten cases were looking normal. Out of 134 cases, 132 underwent appendicectomy, 2 underwent right hemicolectomy (One case with mass and another who had faecal fistula).

The post operative complications were surgical site infection (1 case), lower respiratory infection ( 3 cases), Faecal Fistula (1 case). The surgical site infection was treated by letting out the pus, pus C/S and with suitable antibiotics. The respiratory infection was treated with respiratory toileting, sputum C/S and with suitable antibiotics. The Feacal Fistula case ended up with right hemicolectomy( mass).

The average stay in the hospital was three days. The surgical site infection and respiratory cases had a average stay of Ten days. The Faecal Fistula had a stay of Three weeks.

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HISTOPATHOLOGICAL EXAMINATION

The appendicectomy specimen was sent for the histopathological examination.The process involved are :++

Specimen Transport

o Specimen immersed in 10% formalin Fixation

o Specimen is left immersed for 6 to 12 hrs Grossing

o Cut-up

o Placed small perforated baskets Processing

o Passed through multiple changes of dehydrating and clearing solvents (ethanol and xylene)

Embedding

o Specimen removed from cassettes o Placed in wax filled molds

o Wax poured

o Block allowed to solidify on cold surface Section

o Using microtome specimen is cut to thickness of 3 to 5 micrometer ensuring only a single layer of cells

Straining

o Stained with hematoxylin and eosin o Nuclei are stained blue

o Cytoplasm and extracellular components are stained pink Slide Preparation

o Sections are covered with glass cover slip

The picture depictes heavy acute inflammatory cells infiltrating the appendicular wall from M-mucosa to S-

serosa.

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Compound Microscope

Histology showing acute appendicitis

Histological diagnosis of appendicitis was based on infiltration of the muscularispropria by neutrophil granulocytes. The inflamed appendix is marked as positive (+), the normal appendix is marked as negative (-).

In the Ultra sound positive patients (82) who underwent appendicectomy 74 cases came as HPE positive. Out of the CT positive cases (41) who underwent appendicectomy 39 were HPE Positive. In the CT inconclusive cases (11), who underwent surgery 4 were HPE Positive.

All the patients were followed up for 6 weeks.

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FLOW CHART -A .

469

patients with RIF pain

Clinically assessed using ALVARDO scoring system.

So total 139 + 10 = 149 patients selected for the study.

177 patients with score7 and above

292 patients with score below 7

139 accepted

38 opted out

10 patients developed the required score

FLOW CHART - B.

149 Cases

USG done

HPE + 74 + 39 + 4

82 + USG 67 - /

inconclusive

( 52 + 15 cases of Alternate diagnosis.)

41 + 11 -/IC 15 alternate

diagnosis

SURGERY. 82 + 41 + 11

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STATISTICAL ANALYSIS.

Statistical analysis was performed using the statistical package for the social sciences .Sensitivity, specificity, positive predictive and negative predictive values and accuracy for USG, CT and combined Diagnostic pathway (using USG and CT in USG negative or inconclusive cases) were calculated.

AGE , SEX CHARACTERISTICS.

Number Age Male Female

USG 149 27 85 64

CT 67 26 41 26

USG FINDINGS.

Positive Negative

82 67 (52+15)

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CT FINDINGS.

Positive Negative +Alternate diagnosis

41 26

HISTOPATHOLOGICAL EXAMINATION.

NUMBER OF SURGERY 134 HPE positive 117

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RESULTS

Statistics USG CT USG+CT

Sensitivity 63% 91% 97%

Specificity 75% 92% 69%

+ Predictive Value

90% 95% 92%

-Predicative value

36% 85% 85%

Accuracy 66% 91% 91%

Chart

SURGERY.

Number of Total surgeries : 82 + 41 + 11 = 134 cases.

(USG Positve + CT Positive + CT Negative )

Number of total open appendicectomy : 103 cases.

Number of total laproscopicappendicectomy : 30 cases.

Number of appendicectomy : 133 cases.

Number of hemi colectomy : 2 cases.

(1 mass + 1 ended up with faecal fistula.)

MACROSCOPIC FINDINGS.

Faecolith 10 Gangrene 2 Perforation 7 In the antimesentric border distal to faecolith.

Generalized peritonitis 0

Mass 2 Normal looking. 10

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POST OPERATIVE COMPLICATIONS.

Complications Number of

cases. Treatment.

SSI 1 drainage, pus c/s

empherical antibiotics.

LRI 3 Sputum c/s,antibiotics

Faecal fistula 1 hemicolectomy.

DISCUSSION

We had 469 patients with c/o pain in the right lower abdomen. We clinically assessed everyone using AIVARDO SCORING SYSTEM. We selected patients who scored 7 and above. There were 177 patients scoring 7 and above. In the other group containing 292 patients, in whom 10 patients developed acute appendicitis of score 7 and above.

So totally 177+10 = 187 patients were Alvando score 7 and above.

They were explained about their disease and treatment methods. And they were explained about the study and they were allowed to choose. Totally 149 patients gave consent for our study.

All 149 patients was examined with USG. 82 patients had positive USG. 67 had inconclusive results (IC). 82 USG Positive cases were taken up for surgery. All 82 patients underwent surgery. In 74 patients HPE came as positive and in 8 patients HPE was negative (N).

Out of the 74 patients who underwent surgery, 2 were gangrene, 7 with perforation, in 10 cases Faecolith, The gangrene and perforation cases had faecolith's. In this group post operative complication was SSI

& LRI which was adequately treated.The total hospital stay in complicated cases was 10 days. For the uncomplicated cases it was only 3 days.

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In the remaining 67 patients, 15 had alternate diagnosis . The USG inconclusive cases were subjected to CT scan. Out of 52, 41 were CT positive, 11 CT inconclusive, 15 had alternate diagnosis.

The patient who had alternate diagnosis treated accordingly with specialists concerned and they had regular follow up.

Since the clinical suscipion was high the CT positive and the CT inconclusive cases were both taken up for the surgery. 39 out of 41 were HPE positive. 4 out of 11 CT inconclusive were HPE positive.

In this group we had 2 mass formation cases both ended up with right hemicolectomy.

The sensitivity and specificity of USG in diagnosis of acute appendicitis are 63% and 75% respectively.

The sensitivity and specificity of CT in diagnosis of acute appendicitis are 91% and 92% respectively.

The sensitivity and specificity of Combined use of USG and CT only in USG inconclusive cases in diagnosing acute appendicitis are 97% and 69% respectively.

CONCLUSION

In our study the sensitivity, specificity of USG & CT in clinically suspected acute appendicitis as a diagnostic tool was studied and further correlated with the HPE. For USG the results are, the sensitivity was 63% and the specificity was 75%. For CT the sensitivity was 91% and the specificity was 92% For USG added with CT ( When USG was inconclusive) the sensitivity was 97% and the specificity was 69%. Hence we conclude :

1. CT is better than USG.

2. Acute appendicitis is more of a clinical diagnosis.