Pub Date : 2017-11-01DOI: 10.1016/j.nhccr.2017.10.032
M Mulla, Najam Husain, Anuttara Bhadra *, Naseem Waraich, Amir Rastegar
Introduction
Appendicitis is common surgical emergency with a lifetime risk of about 7% and a perforation risk of 17-20%. In young patients diagnosis does not pose a great difficulty and the surgical management is generally good. However in the elderly with varied presentation and a difficult history, the diagnosis can be more challenging. Small bowel obstruction as a result of adhesions from appendicitis has been commonly documented in literature. But mechanical small bowel obstruction caused directly as a result of acute appendicitis is rare. We present one of this rare and interesting presentation of appendicitis.
Case description
An 83-year-old gentleman presented to the surgical department with a 4-day vague history of abdominal pain associated with vomiting. He had not opened his bowels for a similar time period and also complained of abdominal distension. The patient had an unremarkable past surgical history, with no prior abdominal surgery. General examination showed he was dehydrated, exhausted and looked unwell. His pulse was 94/min, BP was 120/60mmHg and he was apyrexial. His abdomen was markedly distended but soft and non-tender with sluggish bowel sounds. Abdominal x-Rays showed multiple loops of dilated small bowel suggestive of small bowel obstruction. Initially the patient was managed by intravenous fluid resuscitation, nasogastric tube insertion and urethral catheterisation. An arterial blood gas analysis showed significant metabolic acidosis with raised serum lactate and negative base excess. Routine bloods showed raised urea, creatinine and WCC. Despite rigorous resuscitation the patient’s condition deteriorated, hence an emergency laparotomy was performed. At surgery loops of distended small bowel were identified extending proximally from the duodeno-jejunal junction to the distal ileum. At approximately 8cm from the ileo-caecal valve, a small appendix was noticed behind the transition point covered in a phlegmon and surrounding inflammation. A routine appendicectomy was performed and the abdomen was closed after thorough wash out with normal saline. No other abnormality was noticed on laparotomy. Unfortunately the patients died a few days after the operation from pneumonia.
Results and Conclusions
Appendicitis is the second most common surgical abdominal pathology in people over 50yrs of age. The diagnosis in this age group is often delayed compared to the younger group due to a variety of reasons including difficult history and atypical and delayed presentation. In our case the cause of mechanical small bowel obstruction was noted to be due to inflamed small appendix and phlegmon lying behind the terminal ileum. Presumably the patient must have developed appendicitis a few days prior to presentation to the hospital. This delay had caused the development of phlegmon in which the appendix was found wrapped causing intestinal obstruction. Mechanical small bowel o
{"title":"A phlegmon secondary to retroileal appendicitis: A rare cause of mechanical small bowel obstruction","authors":"M Mulla, Najam Husain, Anuttara Bhadra *, Naseem Waraich, Amir Rastegar","doi":"10.1016/j.nhccr.2017.10.032","DOIUrl":"10.1016/j.nhccr.2017.10.032","url":null,"abstract":"<div><h3>Introduction</h3><p>Appendicitis is common surgical emergency with a lifetime risk of about 7% and a perforation risk of 17-20%. In young patients diagnosis does not pose a great difficulty and the surgical management is generally good. However in the elderly with varied presentation and a difficult history, the diagnosis can be more challenging. Small bowel obstruction as a result of adhesions from appendicitis has been commonly documented in literature. But mechanical small bowel obstruction caused directly as a result of acute appendicitis is rare. We present one of this rare and interesting presentation of appendicitis.</p></div><div><h3>Case description</h3><p>An 83-year-old gentleman presented to the surgical department with a 4-day vague history of abdominal pain associated with vomiting. He had not opened his bowels for a similar time period and also complained of abdominal distension. The patient had an unremarkable past surgical history, with no prior abdominal surgery. General examination showed he was dehydrated, exhausted and looked unwell. His pulse was 94/min, BP was 120/60mmHg and he was apyrexial. His abdomen was markedly distended but soft and non-tender with sluggish bowel sounds. Abdominal x-Rays showed multiple loops of dilated small bowel suggestive of small bowel obstruction. Initially the patient was managed by intravenous fluid resuscitation, nasogastric tube insertion and urethral catheterisation. An arterial blood gas analysis showed significant metabolic acidosis with raised serum lactate and negative base excess. Routine bloods showed raised urea, creatinine and WCC. Despite rigorous resuscitation the patient’s condition deteriorated, hence an emergency laparotomy was performed. At surgery loops of distended small bowel were identified extending proximally from the duodeno-jejunal junction to the distal ileum. At approximately 8cm from the ileo-caecal valve, a small appendix was noticed behind the transition point covered in a phlegmon and surrounding inflammation. A routine appendicectomy was performed and the abdomen was closed after thorough wash out with normal saline. No other abnormality was noticed on laparotomy. Unfortunately the patients died a few days after the operation from pneumonia.</p></div><div><h3>Results and Conclusions</h3><p>Appendicitis is the second most common surgical abdominal pathology in people over 50yrs of age. The diagnosis in this age group is often delayed compared to the younger group due to a variety of reasons including difficult history and atypical and delayed presentation. In our case the cause of mechanical small bowel obstruction was noted to be due to inflamed small appendix and phlegmon lying behind the terminal ileum. Presumably the patient must have developed appendicitis a few days prior to presentation to the hospital. This delay had caused the development of phlegmon in which the appendix was found wrapped causing intestinal obstruction. Mechanical small bowel o","PeriodicalId":100954,"journal":{"name":"New Horizons in Clinical Case Reports","volume":"2 ","pages":"Pages 32-33"},"PeriodicalIF":0.0,"publicationDate":"2017-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1016/j.nhccr.2017.10.032","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"91285995","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2017-11-01DOI: 10.1016/j.nhccr.2017.10.007
Tom Langenaeken *, Xavier De Raeymaeker, Aaron De Poortere, Filip Rega, Wouter Oosterlinck
Introduction
Coronary artery disease is frequently associated with aortic stenosis. Using minimally invasive direct coronary artery bypass (MIDCAB), we conducted a single bypass of the LAD using the LIMA on an 87-year-old patient with TAVI-prothesis and pacemaker. This case report describes the procedure for our rather special patient, from intake to discharge.
Case description
A 87-year-old male was admitted to our hospital due to NONSTEMI. Surgical history included TAVI Corevalve® endoprothesis (81y.o.) and BIOTRONIK pacemaker for left bundle branch block. We opted for minimally invasive direct coronary artery bypass (MIDCAB) using the Da Vinci® Robot System. There were no adverse events in the postoperative period. Patient was discharged on the 8th postoperative day. Several questions arose while treating our rather complex patient: what is the optimal timing for revascularization after TAVI and what method of revascularization should be used?
Results and Conclusions
We consider TAVI followed by MIDCAB as a feasible approach for these complex patients. It is potentially beneficial regarding blood loss and hospital stay. The staged approach avoids many risks described in literature. Research is needed to support this intuitive assumption; the effect of TAVI on coronary hemodynamics on the long term as well as comparing combined and staged TAVI-MIDCAB could be interesting subjects for further investigation.
Take home message
A staged minimal invasive procedure with TAVI and followed by MIDCAB might be beneficial in octogenarians.
{"title":"Minimally invasive direct coronary artery bypass and TAVI: Timing and considerations in octogenarians: A case report","authors":"Tom Langenaeken *, Xavier De Raeymaeker, Aaron De Poortere, Filip Rega, Wouter Oosterlinck","doi":"10.1016/j.nhccr.2017.10.007","DOIUrl":"10.1016/j.nhccr.2017.10.007","url":null,"abstract":"<div><h3>Introduction</h3><p>Coronary artery disease is frequently associated with aortic stenosis. Using minimally invasive direct coronary artery bypass (MIDCAB), we conducted a single bypass of the LAD using the LIMA on an 87-year-old patient with TAVI-prothesis and pacemaker. This case report describes the procedure for our rather special patient, from intake to discharge.</p></div><div><h3>Case description</h3><p>A 87-year-old male was admitted to our hospital due to NONSTEMI. Surgical history included TAVI Corevalve® endoprothesis (81y.o.) and BIOTRONIK pacemaker for left bundle branch block. We opted for minimally invasive direct coronary artery bypass (MIDCAB) using the Da Vinci® Robot System. There were no adverse events in the postoperative period. Patient was discharged on the 8<sup>th</sup> postoperative day. Several questions arose while treating our rather complex patient: what is the optimal timing for revascularization after TAVI and what method of revascularization should be used?</p></div><div><h3>Results and Conclusions</h3><p>We consider TAVI followed by MIDCAB as a feasible approach for these complex patients. It is potentially beneficial regarding blood loss and hospital stay. The staged approach avoids many risks described in literature. Research is needed to support this intuitive assumption; the effect of TAVI on coronary hemodynamics on the long term as well as comparing combined and staged TAVI-MIDCAB could be interesting subjects for further investigation.</p></div><div><h3>Take home message</h3><p>A staged minimal invasive procedure with TAVI and followed by MIDCAB might be beneficial in octogenarians.</p></div>","PeriodicalId":100954,"journal":{"name":"New Horizons in Clinical Case Reports","volume":"2 ","pages":"Pages 22-23"},"PeriodicalIF":0.0,"publicationDate":"2017-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1016/j.nhccr.2017.10.007","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"91126023","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2017-11-01DOI: 10.1016/j.nhccr.2017.10.028
Mohammad Mirza *, Najam Husain, Naseem Waraich
Introduction
Nicorandil is an antianginal drug whose link with oral and anal ulcers is well established. Through this case we hope to demonstrate that ulcers and perforations caused by nicorandil may also occur in the terminal ileum and may reoccur unless nicorandil is held. This is the first reported case of recurrent nicorandil induced perforations.
Case description
A seventy eight year old woman presented to hospital three times over a 4 months period with symptoms of an acute abdomen. On all three occasions she was found to have a perforation of the terminal ilium. She underwent laparotomies on the first two occasions with resection of a segment of the small bowel on the second. It was not until the third such event that her Nicorandil was implicated as the cause. This was duly stopped and she has been well since.
Conclusions
The likely hood of developing a GI ulcer is higher amongst nicorandil users. This occurrence is not just limited to the oral and anal regions but may occur all along the GI tract. Our case highlights nicorandil’s detrimental effects on the GI tract. It also suggests the early withdrawal Nicorandil as the optimum means of achieving remission.
Take home message
The authors propose that Nicorandil be withdrawn in cases of GI perforation to avert the risk a recurrence.
{"title":"Nicorandil: A rare cause of recurrent ileal perforation","authors":"Mohammad Mirza *, Najam Husain, Naseem Waraich","doi":"10.1016/j.nhccr.2017.10.028","DOIUrl":"10.1016/j.nhccr.2017.10.028","url":null,"abstract":"<div><h3>Introduction</h3><p>Nicorandil is an antianginal drug whose link with oral and anal ulcers is well established. Through this case we hope to demonstrate that ulcers and perforations caused by nicorandil may also occur in the terminal ileum and may reoccur unless nicorandil is held. This is the first reported case of recurrent nicorandil induced perforations.</p></div><div><h3>Case description</h3><p>A seventy eight year old woman presented to hospital three times over a 4 months period with symptoms of an acute abdomen. On all three occasions she was found to have a perforation of the terminal ilium. She underwent laparotomies on the first two occasions with resection of a segment of the small bowel on the second. It was not until the third such event that her Nicorandil was implicated as the cause. This was duly stopped and she has been well since.</p></div><div><h3>Conclusions</h3><p>The likely hood of developing a GI ulcer is higher amongst nicorandil users. This occurrence is not just limited to the oral and anal regions but may occur all along the GI tract. Our case highlights nicorandil’s detrimental effects on the GI tract. It also suggests the early withdrawal Nicorandil as the optimum means of achieving remission.</p></div><div><h3>Take home message</h3><p>The authors propose that Nicorandil be withdrawn in cases of GI perforation to avert the risk a recurrence.</p></div>","PeriodicalId":100954,"journal":{"name":"New Horizons in Clinical Case Reports","volume":"2 ","pages":"Page 31"},"PeriodicalIF":0.0,"publicationDate":"2017-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1016/j.nhccr.2017.10.028","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"86837075","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2017-11-01DOI: 10.1016/j.nhccr.2017.10.021
Anuttara Bhadra *, Najam Husain, Amir Rastegar, James Eccersley, Joshua Agilinko
Introduction
Spontaneous pneumomediastinum (SPM) is rare, with an incidence of 1/25,000. It is defined as extra luminal free air within the mediastinum, not associated with trauma. A classic clinical triad consists of pleuritic chest pain, dyspnoea and subcutaneous emphysema. SPM is self-limiting and symptoms can be managed conservatively. However despite a good prognosis, secondary causes should be excluded.
Case description
Miss AG, 27 year old with a known history of Ulcerative Colitis being treated with azathioprine and adalimumab, presented to the ED with a two week history of progressively worsening shortness of breath and left sided pleuritic chest pain. She reported a 3 day h/o ongoing fever, rigors for which she was being treated with Amoxicillin 500mg tds. The patient had no previous history of respiratory conditions and was a non-smoker. The patient saturated at 96% on 2L of Oxygen with a respiratory rate of 19. She was apyrexial, normotensive and acyanotic. Clinical findings on auscultation revealed left sided bronchial breathing, an erect postero-anterior chest x-ray revealed dense opacification throughout the left mid and lower zone. As she was increasingly symptomatic, she went onto have a CTPA, which showed a pneumomediastinum. A discussion with the thoracic surgeons followed and an urgent CT thorax and abdomen with oral gastrografin was carried out to exclude oesophageal perforation. This scan did not reveal any extravasation of contrast around the oesophagus to suggest a perforation or a leak. The patient improved clinically, discharged in 6 days, she was kept nil by mouth for 48 hours once the CT had confirmed that there was no perforation.
Results and Conclusions
SPM usually has a benign and favourable clinical course and is usually self-limiting. It is more commonly seen in young men. The pathophysiological process behind SPM was initially described by Macklin in 1944, who described a rupture of the terminal alveoli, secondary to pressure differences across the alveolar membrane causing air to leak into the lung interstitium and consequently into them mediastinum. In a retrospective study by Park et al., 44% of the patients had a precipitating factor, with the most common being cough.
Literature suggests that the most common symptoms reported in cases are usually chest pain, which is usually pleuritic in nature and dyspnoea Subcutaneous emphysema is also reported as common clinical sign and has a frequency ranging from 40% to 100% in cases. Moreover, the characteristic sign of systolic crackles on auscultation known as Hamman’s sign can also be heard in 30% of cases. Diagnosis in this case was made based on the CTPA though it is more commonly based on chest x-ray findings. Postero-anterior view establishes the diagnosis in about two-thirds of patients with the three commonest findings: air streaks in the superior mediastinum, prominent left sided silhouet
{"title":"An unusual case of spontaneous pneumomediastinum: Case report","authors":"Anuttara Bhadra *, Najam Husain, Amir Rastegar, James Eccersley, Joshua Agilinko","doi":"10.1016/j.nhccr.2017.10.021","DOIUrl":"10.1016/j.nhccr.2017.10.021","url":null,"abstract":"<div><h3>Introduction</h3><p>Spontaneous pneumomediastinum (SPM) is rare, with an incidence of 1/25,000. It is defined as extra luminal free air within the mediastinum, not associated with trauma. A classic clinical triad consists of pleuritic chest pain, dyspnoea and subcutaneous emphysema. SPM is self-limiting and symptoms can be managed conservatively. However despite a good prognosis, secondary causes should be excluded.</p></div><div><h3>Case description</h3><p>Miss AG, 27 year old with a known history of Ulcerative Colitis being treated with azathioprine and adalimumab, presented to the ED with a two week history of progressively worsening shortness of breath and left sided pleuritic chest pain. She reported a 3 day h/o ongoing fever, rigors for which she was being treated with Amoxicillin 500mg tds. The patient had no previous history of respiratory conditions and was a non-smoker. The patient saturated at 96% on 2L of Oxygen with a respiratory rate of 19. She was apyrexial, normotensive and acyanotic. Clinical findings on auscultation revealed left sided bronchial breathing, an erect postero-anterior chest x-ray revealed dense opacification throughout the left mid and lower zone. As she was increasingly symptomatic, she went onto have a CTPA, which showed a pneumomediastinum. A discussion with the thoracic surgeons followed and an urgent CT thorax and abdomen with oral gastrografin was carried out to exclude oesophageal perforation. This scan did not reveal any extravasation of contrast around the oesophagus to suggest a perforation or a leak. The patient improved clinically, discharged in 6 days, she was kept nil by mouth for 48 hours once the CT had confirmed that there was no perforation.</p></div><div><h3>Results and Conclusions</h3><p>SPM usually has a benign and favourable clinical course and is usually self-limiting. It is more commonly seen in young men. The pathophysiological process behind SPM was initially described by Macklin in 1944, who described a rupture of the terminal alveoli, secondary to pressure differences across the alveolar membrane causing air to leak into the lung interstitium and consequently into them mediastinum. In a retrospective study by Park et al., 44% of the patients had a precipitating factor, with the most common being cough.</p><p>Literature suggests that the most common symptoms reported in cases are usually chest pain, which is usually pleuritic in nature and dyspnoea Subcutaneous emphysema is also reported as common clinical sign and has a frequency ranging from 40% to 100% in cases. Moreover, the characteristic sign of systolic crackles on auscultation known as Hamman’s sign can also be heard in 30% of cases. Diagnosis in this case was made based on the CTPA though it is more commonly based on chest x-ray findings. Postero-anterior view establishes the diagnosis in about two-thirds of patients with the three commonest findings: air streaks in the superior mediastinum, prominent left sided silhouet","PeriodicalId":100954,"journal":{"name":"New Horizons in Clinical Case Reports","volume":"2 ","pages":"Pages 28-29"},"PeriodicalIF":0.0,"publicationDate":"2017-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1016/j.nhccr.2017.10.021","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"82625916","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2017-11-01DOI: 10.1016/j.nhccr.2017.08.003
Joshua Agilinko, Naseem Waraich
Objective
To evaluate the diagnostic accuracy of the Alvarado score in reducing the rate of negative appendicectomy at Queen’s Hospital, a small district general hospital in England.
Methodology
The retrospective, analytical study included all children who were ≤16 years old with a preliminary diagnosis of acute appendicitis undergoing appendicectomy subsequently. Children with other causes of acute abdominal pain were excluded from the study. A total of 118 patients were included. Based on their calculated Alvarado scores, they were stratified into two groups: Group A (Alvarado score <6) and Group B (Alvarado score ≥6). Alvarado scores were compared with the histopathology reports, the gold standard for diagnosing acute appendicitis. The data gathered was then subjected to statistical analysis to measure our objective.
Results
Out of the 118 patients (85 males, 33 females), 46 belonged to Group A and 72 to Group B.
Final diagnosis of acute appendicitis from histopathology reports was confirmed in 94 cases (79.6%). The overall sensitivity and positive predictive value of Alvarado score for acute appendicitis were 92% and 94% respectively. The area under the ROC curve was 0.9 indicating a highly accurate test.
The sensitivity was only slightly higher for males with a score of <6 than females (94.9% vs. 89.5%, p < 0.05).
However, for scores ≥6, sensitivity among males was significantly higher than females (79% vs. 62.6%; p < 0.05).
A multivariate analysis revealed that anorexia, right iliac fossa tenderness and rebound tenderness are significantly correlated with a correct diagnosis of acute appendicitis (p = 0.025, 0.037 and 0.026 respectively).
Conclusion
The presence of a high Alvarado score (≥6) is highly predictive of acute appendicitis.
In women of childbearing age and Alvarado scores of <6, other pathologies that mimic appendicitis must be considered. An US scan of abdomen and pelvis should be considered in a woman of child-bearing age before proceeding to a surgical intervention.
目的评价Alvarado评分在降低英国女王医院阑尾切除术阴性率中的诊断准确性。方法回顾性分析研究纳入所有≤16岁初步诊断为急性阑尾炎并随后行阑尾切除术的儿童。有其他急性腹痛原因的儿童被排除在研究之外。共纳入118例患者。根据计算的Alvarado评分，将患者分为A组(Alvarado评分<6)和B组(Alvarado评分≥6)。将Alvarado评分与诊断急性阑尾炎的金标准组织病理学报告进行比较。然后对收集到的数据进行统计分析，以衡量我们的目标。结果118例患者(男85例，女33例)中，A组46例，b组72例，经组织病理学报告确诊急性阑尾炎94例(79.6%)。Alvarado评分对急性阑尾炎的总体敏感性为92%，阳性预测值为94%。ROC曲线下的面积为0.9，表明测试非常准确。得分为<6的男性的敏感性仅略高于女性(94.9% vs. 89.5%， p <0.05)。然而，对于评分≥6分，男性的敏感性显著高于女性(79% vs. 62.6%;p & lt;0.05)。多因素分析显示，厌食症、右髂窝压痛和反跳压痛与急性阑尾炎的正确诊断有显著相关性(p分别为0.025、0.037和0.026)。结论高Alvarado评分(≥6)对急性阑尾炎具有较高的预测价值。在育龄妇女和阿尔瓦拉多评分为<6，其他病理模拟阑尾炎必须考虑。育龄妇女在进行手术前应考虑腹部和骨盆的超声扫描。
{"title":"The Alvarado score in acute appendicitis: A 3-year audit to evaluate the usefulness in predicting negative appendicectomies in ≤16 s at QHBFT","authors":"Joshua Agilinko, Naseem Waraich","doi":"10.1016/j.nhccr.2017.08.003","DOIUrl":"10.1016/j.nhccr.2017.08.003","url":null,"abstract":"<div><h3>Objective</h3><p>To evaluate the diagnostic accuracy of the Alvarado score in reducing the rate of negative appendicectomy at Queen’s Hospital, a small district general hospital in England.</p></div><div><h3>Methodology</h3><p>The retrospective, analytical study included all children who were ≤16 years old with a preliminary diagnosis of acute appendicitis undergoing appendicectomy subsequently. Children with other causes of acute abdominal pain were excluded from the study. A total of 118 patients were included. Based on their calculated Alvarado scores, they were stratified into two groups: Group A (Alvarado score <6) and Group B (Alvarado score ≥6). Alvarado scores were compared with the histopathology reports, the gold standard for diagnosing acute appendicitis. The data gathered was then subjected to statistical analysis to measure our objective.</p></div><div><h3>Results</h3><p>Out of the 118 patients (85 males, 33 females), 46 belonged to Group A and 72 to Group B.</p><p>Final diagnosis of acute appendicitis from histopathology reports was confirmed in 94 cases (79.6%). The overall sensitivity and positive predictive value of Alvarado score for acute appendicitis were 92% and 94% respectively. The area under the ROC curve was 0.9 indicating a highly accurate test.</p><p>The sensitivity was only slightly higher for males with a score of <6 than females (94.9% vs. 89.5%, p < 0.05).</p><p>However, for scores ≥6, sensitivity among males was significantly higher than females (79% vs. 62.6%; p < 0.05).</p><p>A multivariate analysis revealed that anorexia, right iliac fossa tenderness and rebound tenderness are significantly correlated with a correct diagnosis of acute appendicitis (p = 0.025, 0.037 and 0.026 respectively).</p></div><div><h3>Conclusion</h3><p>The presence of a high Alvarado score (≥6) is highly predictive of acute appendicitis.</p><p>In women of childbearing age and Alvarado scores of <6, other pathologies that mimic appendicitis must be considered. An US scan of abdomen and pelvis should be considered in a woman of child-bearing age before proceeding to a surgical intervention.</p></div>","PeriodicalId":100954,"journal":{"name":"New Horizons in Clinical Case Reports","volume":"2 ","pages":"Pages 12-14"},"PeriodicalIF":0.0,"publicationDate":"2017-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1016/j.nhccr.2017.08.003","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"91087105","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2017-11-01DOI: 10.1016/j.nhccr.2017.10.034
Azzam Al-Amin *, Muhammad Shiwani
Introduction
We describe a case of successful laparoscopic cholecystectomy using a “double bag technique" to retrieve giant gall stone. Laparoscopic removal of gallstones within the gallbladder, larger than 5cm have rarely been reported in the literature.
Case description
A 44 year old woman presented to the outpatient surgical clinic with symptomatic gallstones. She otherwise had no other medical problems. However, her BMI was 40.9.
Results and Conclusions
Blood tests were within the normal range. Her ultrasound scan report showed ‘many gallstones within the body of the gallbladder, the largest approximately 1cm’. During her laparoscopic cholecystectomy, a very large, 8cm gallstone was encountered in the fundus of the gallbladder.
The gallbladder wall was opened and the stone extracted and placed in the right paracolic gutter, adjacent to the liver. A standard laparoscopic cholecystectomy was then performed. The gallbladder and the ‘giant stone’ were extracted separately. The former via “BertTM bag” 80ml capacity and latter via the “AnchorTM tissue retrieval system device TRS100SB2” 235ml capacity – using the “pack and push the envelope” technique.
Take home message
This case highlights that it is possible to retrieve a giant stone laparoscopically, without the need to convert to open procedure, using the above technique. It is important for the surgeon to be familiar with the various tissue retrieval systems available.
{"title":"Successful laparoscopic cholecystectomy for giant gallstone using a ‘double-bag' technique in an obese patient","authors":"Azzam Al-Amin *, Muhammad Shiwani","doi":"10.1016/j.nhccr.2017.10.034","DOIUrl":"10.1016/j.nhccr.2017.10.034","url":null,"abstract":"<div><h3>Introduction</h3><p>We describe a case of successful laparoscopic cholecystectomy using a “double bag technique\" to retrieve giant gall stone. Laparoscopic removal of gallstones within the gallbladder, larger than 5cm have rarely been reported in the literature.</p></div><div><h3>Case description</h3><p>A 44 year old woman presented to the outpatient surgical clinic with symptomatic gallstones. She otherwise had no other medical problems. However, her BMI was 40.9.</p></div><div><h3>Results and Conclusions</h3><p>Blood tests were within the normal range. Her ultrasound scan report showed ‘<em>many gallstones within the body of the gallbladder, the largest approximately 1cm’.</em> During her laparoscopic cholecystectomy, a very large, 8cm gallstone was encountered in the fundus of the gallbladder.</p><p>The gallbladder wall was opened and the stone extracted and placed in the right paracolic gutter, adjacent to the liver. A standard laparoscopic cholecystectomy was then performed. The gallbladder and the ‘giant stone’ were extracted separately. The former via “Bert<sup>TM</sup> bag” 80ml capacity and latter via the “Anchor<sup>TM</sup> tissue retrieval system device TRS100SB2” 235ml capacity – using the “pack and push the envelope” technique.</p></div><div><h3>Take home message</h3><p>This case highlights that it is possible to retrieve a giant stone laparoscopically, without the need to convert to open procedure, using the above technique. It is important for the surgeon to be familiar with the various tissue retrieval systems available.</p></div>","PeriodicalId":100954,"journal":{"name":"New Horizons in Clinical Case Reports","volume":"2 ","pages":"Page 33"},"PeriodicalIF":0.0,"publicationDate":"2017-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1016/j.nhccr.2017.10.034","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"78849250","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2017-11-01DOI: 10.1016/j.nhccr.2017.10.013
A Trippel * , R Cathomas , C Michelitsch , M Furrer
Objectives
Desmoid Tumors (DT) are rare locally aggressive and never metastasizing mesenchymal tumors. They usually grow slowly and often present on the trunk or extremity, on the abdominal wall or intra-abdominally. Radical surgical removal has been considered the treatment of choice for many years, although high recurrence rates ranging from 30% to 40% have been reported.
Methods
A 40-year old woman was referred to our department with a 4cmx2cmx3cm painless hard tumor on the lateral wall of the right thorax. A histological diagnosis of a DT was made after a biopsy specimen was obtained. After initial R0 surgical resection the patient developed a chronic pain syndrome. Another surgical R0 resection was performed after local recurrence was noted in an MRI fifteen months postoperative. 30 months after the first operation and 17 months after the second operation a second local recurrence was seen. A third operation was planned but the patient chose not to undergo surgery and was referred to the medical oncologist. A therapy with tamoxifen was started and supplemented with sulindac after two months since a tumor progression was shown in the first follow up MRI.
Results
The follow up under the tamoxifen/sulindac therapy showed disease stabilization after 12 months and a complete tumor regression after 1½ years. The tamoxifen/sulindac regimen and the follow-up were continued, and the patient is now tumor free after 3½ years of medical treatment. The pain syndrome has also improved although the patient is still under oxycodone therapy.
Conclusions
In current practice, the treatment of desmoid tumor medical therapy was reserved to unresectable disease or where radical resection would have brought to major functional or cosmetic losses. This present case calls into question the established surgical therapy of desmoid tumors. Although a strong evidence-based treatment is still missing, other recent studies have also suggested alternative different therapeutic strategies based on a “wait and see” strategy may be effective in the case of asymptomatic disease.
{"title":"Changing standards in the treatment of desmoid tumors?","authors":"A Trippel * , R Cathomas , C Michelitsch , M Furrer","doi":"10.1016/j.nhccr.2017.10.013","DOIUrl":"10.1016/j.nhccr.2017.10.013","url":null,"abstract":"<div><h3>Objectives</h3><p>Desmoid Tumors (DT) are rare locally aggressive and never metastasizing mesenchymal tumors. They usually grow slowly and often present on the trunk or extremity, on the abdominal wall or intra-abdominally. Radical surgical removal has been considered the treatment of choice for many years, although high recurrence rates ranging from 30% to 40% have been reported.</p></div><div><h3>Methods</h3><p>A 40-year old woman was referred to our department with a 4cmx2cmx3cm painless hard tumor on the lateral wall of the right thorax. A histological diagnosis of a DT was made after a biopsy specimen was obtained. After initial R0 surgical resection the patient developed a chronic pain syndrome. Another surgical R0 resection was performed after local recurrence was noted in an MRI fifteen months postoperative. 30 months after the first operation and 17 months after the second operation a second local recurrence was seen. A third operation was planned but the patient chose not to undergo surgery and was referred to the medical oncologist. A therapy with tamoxifen was started and supplemented with sulindac after two months since a tumor progression was shown in the first follow up MRI.</p></div><div><h3>Results</h3><p>The follow up under the tamoxifen/sulindac therapy showed disease stabilization after 12 months and a complete tumor regression after 1½ years. The tamoxifen/sulindac regimen and the follow-up were continued, and the patient is now tumor free after 3½ years of medical treatment. The pain syndrome has also improved although the patient is still under oxycodone therapy.</p></div><div><h3>Conclusions</h3><p>In current practice, the treatment of desmoid tumor medical therapy was reserved to unresectable disease or where radical resection would have brought to major functional or cosmetic losses. This present case calls into question the established surgical therapy of desmoid tumors. Although a strong evidence-based treatment is still missing, other recent studies have also suggested alternative different therapeutic strategies based on a “wait and see” strategy may be effective in the case of asymptomatic disease.</p></div>","PeriodicalId":100954,"journal":{"name":"New Horizons in Clinical Case Reports","volume":"2 ","pages":"Page 25"},"PeriodicalIF":0.0,"publicationDate":"2017-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1016/j.nhccr.2017.10.013","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"79271602","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2017-11-01DOI: 10.1016/j.nhccr.2017.10.020
Yan Mei Goh *, P Bijoor, Henry Andrews
Introduction
Vesico-uterine fistula (VUF) is a recognised but rare complication following lower segment caesarean section with an incidence of less than 4% of all urogenital fistulae. Patients commonly present with urinary incontinence, cyclical haematuria, amenorrhoea, infertility and spontaneous first trimester abortions. Presentation can be immediate or delayed.
Case description
A 34-year-old lady presents with an eight-day history of continuous urinary leakage, following LSCS. She had the operation due to failure to progress during labour. She was discharged home after 2 days only to re-present. Speculum examination revealed drainage of clear fluid from the vagina. A vesico-vaginal fistula (VVF) was suspected and she underwent intravenous urogram (IVU) and CT abdomen and pelvis. Radiological findings revealed a suspected fistula but its precise anatomy was uncertain, hence a diagnosis was not made. She underwent examination under anaesthesia, cystoscopy, colposcopy and hysteroscopy, which revealed a small defect in the dome of the bladder and further advancement of the scope led to an entry into a second confined space – the uterus. Clearly there was communication between these spaces. A hysteroscopy revealed missing anterior aspect of the cervix, and proximal to this was the fistula. A urinary catheter was inserted and elective laparotomy planned in six weeks to allow for uterine involution. On the day of her operation, the patient reported cessation of urinary leakage and felt there was no significant vaginal discharge. The assumption was that her fistula had closed spontaneously. A formal cystogram was performed showing the presence of contrast within two cavities. Methylene blue dye was instilled into the bladder via the urinary catheter. Blue staining on the cervix end of the tampon confirmed a patent fistula tract. She underwent laparotomy where the bladder was bivalved to separate it from the anterior aspect of the uterus and cervix, the fistulous tract was excised, and the bladder repaired. An omental ‘tongue’ was place as interposition between the uterus and the bladder. Her post-operative recovery was uneventful and she was discharged home. On review 6 weeks post-operatively, she had made a full recovery with no further urinary leakage.
Results and Conclusions
VUF is an unusual complication of LCSC, and presentation is very variable, from frank urinary leakage to vaginal discharge. What makes it unique is a competent cervix, which closes and allows urine to be trapped in to the uterus. This creates the variability of the intensity of discharge - if at all and other non-specific presentation as previously alluded to. A high index of suspicion is therefore required to make this diagnosis, as cystograms may not necessarily fill the uterus, especially if already involuted. For the same reasons, VUF may present early following caesarean section or as a delayed presentation
{"title":"A very rare complication of vesico-uterine fistula following lower segment caesarean section","authors":"Yan Mei Goh *, P Bijoor, Henry Andrews","doi":"10.1016/j.nhccr.2017.10.020","DOIUrl":"10.1016/j.nhccr.2017.10.020","url":null,"abstract":"<div><h3>Introduction</h3><p>Vesico-uterine fistula (VUF) is a recognised but rare complication following lower segment caesarean section with an incidence of less than 4% of all urogenital fistulae. Patients commonly present with urinary incontinence, cyclical haematuria, amenorrhoea, infertility and spontaneous first trimester abortions. Presentation can be immediate or delayed.</p></div><div><h3>Case description</h3><p>A 34-year-old lady presents with an eight-day history of continuous urinary leakage, following LSCS. She had the operation due to failure to progress during labour. She was discharged home after 2 days only to re-present. Speculum examination revealed drainage of clear fluid from the vagina. A vesico-vaginal fistula (VVF) was suspected and she underwent intravenous urogram (IVU) and CT abdomen and pelvis. Radiological findings revealed a suspected fistula but its precise anatomy was uncertain, hence a diagnosis was not made. She underwent examination under anaesthesia, cystoscopy, colposcopy and hysteroscopy, which revealed a small defect in the dome of the bladder and further advancement of the scope led to an entry into a second confined space – the uterus. Clearly there was communication between these spaces. A hysteroscopy revealed missing anterior aspect of the cervix, and proximal to this was the fistula. A urinary catheter was inserted and elective laparotomy planned in six weeks to allow for uterine involution. On the day of her operation, the patient reported cessation of urinary leakage and felt there was no significant vaginal discharge. The assumption was that her fistula had closed spontaneously. A formal cystogram was performed showing the presence of contrast within two cavities. Methylene blue dye was instilled into the bladder via the urinary catheter. Blue staining on the cervix end of the tampon confirmed a patent fistula tract. She underwent laparotomy where the bladder was bivalved to separate it from the anterior aspect of the uterus and cervix, the fistulous tract was excised, and the bladder repaired. An omental ‘tongue’ was place as interposition between the uterus and the bladder. Her post-operative recovery was uneventful and she was discharged home. On review 6 weeks post-operatively, she had made a full recovery with no further urinary leakage.</p></div><div><h3>Results and Conclusions</h3><p>VUF is an unusual complication of LCSC, and presentation is very variable, from frank urinary leakage to vaginal discharge. What makes it unique is a competent cervix, which closes and allows urine to be trapped in to the uterus. This creates the variability of the intensity of discharge - if at all and other non-specific presentation as previously alluded to. A high index of suspicion is therefore required to make this diagnosis, as cystograms may not necessarily fill the uterus, especially if already involuted. For the same reasons, VUF may present early following caesarean section or as a delayed presentation","PeriodicalId":100954,"journal":{"name":"New Horizons in Clinical Case Reports","volume":"2 ","pages":"Page 28"},"PeriodicalIF":0.0,"publicationDate":"2017-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1016/j.nhccr.2017.10.020","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"77504278","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2017-11-01DOI: 10.1016/j.nhccr.2017.10.019
Kate Richards *, Kai Wong, Mansoor Khan
Introduction
There are an increasing number of reported injuries associated with ambulatory mobile phone use. PokemonGo is one of the first mobile augmented reality games. We present a case of electrical burns in a PokemonGo player.
Case description
A young male sustained high voltage electrical burns from falling onto a railway track whilst playing PokemonGo. Injuries involved 7% full thickness burns affecting both lower limbs, chest, right elbow and right maxilla. This was associated with loss of motor function in his right foot. Emergency fasciotomies were performed. He required extensive wound debridement, including a large portion of his extensor mechanism. Rhabdomyolysis was treated with intravenous fluids. Due to extensive loss of anterior thigh muscles and common peroneal nerve damage from the injury, he subsequently had an above knee amputation.
Results and Conclusions
Mobile phone use by drivers is widely acknowledged to contribute towards accidents and injuries. Pedestrian mobile use has been identified as having a similar effect on user safety. The rate of increase of pedestrian injuries associated with mobile phone use surpasses that of motor vehicle drivers, although it is anticipated that this remains under-reported. Mobile phone use impacts on situational awareness and causes temporary user distraction. In addition augmented reality games blur the distinction between the physical and computer world, impairing judgement. Recently safety measures targeting distracted pedestrians have been considered. These include education, signs, separated walkways for device users and fines.
Take home message
Use of mobile devices impairs situational awareness and co-ordination. Increased awareness and reporting of injuries associated with device use is important in informing the public and healthcare providers. Further measures are required to target this public safety concern.
{"title":"Augmented reality game related injuries","authors":"Kate Richards *, Kai Wong, Mansoor Khan","doi":"10.1016/j.nhccr.2017.10.019","DOIUrl":"10.1016/j.nhccr.2017.10.019","url":null,"abstract":"<div><h3>Introduction</h3><p>There are an increasing number of reported injuries associated with ambulatory mobile phone use. PokemonGo is one of the first mobile augmented reality games. We present a case of electrical burns in a PokemonGo player.</p></div><div><h3>Case description</h3><p>A young male sustained high voltage electrical burns from falling onto a railway track whilst playing PokemonGo. Injuries involved 7% full thickness burns affecting both lower limbs, chest, right elbow and right maxilla. This was associated with loss of motor function in his right foot. Emergency fasciotomies were performed. He required extensive wound debridement, including a large portion of his extensor mechanism. Rhabdomyolysis was treated with intravenous fluids. Due to extensive loss of anterior thigh muscles and common peroneal nerve damage from the injury, he subsequently had an above knee amputation.</p></div><div><h3>Results and Conclusions</h3><p>Mobile phone use by drivers is widely acknowledged to contribute towards accidents and injuries. Pedestrian mobile use has been identified as having a similar effect on user safety. The rate of increase of pedestrian injuries associated with mobile phone use surpasses that of motor vehicle drivers, although it is anticipated that this remains under-reported. Mobile phone use impacts on situational awareness and causes temporary user distraction. In addition augmented reality games blur the distinction between the physical and computer world, impairing judgement. Recently safety measures targeting distracted pedestrians have been considered. These include education, signs, separated walkways for device users and fines.</p></div><div><h3>Take home message</h3><p>Use of mobile devices impairs situational awareness and co-ordination. Increased awareness and reporting of injuries associated with device use is important in informing the public and healthcare providers. Further measures are required to target this public safety concern.</p></div>","PeriodicalId":100954,"journal":{"name":"New Horizons in Clinical Case Reports","volume":"2 ","pages":"Page 27"},"PeriodicalIF":0.0,"publicationDate":"2017-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1016/j.nhccr.2017.10.019","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"82343241","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2017-11-01DOI: 10.1016/j.nhccr.2017.10.031
Joshua Agilinko *, Naseem Waraich
Introduction
Globally, acute appendicitis is the most common paediatric intra-abdominal surgical emergency. The variations at presentation and the lack of a single reliable test to aid diagnosis may pose challenges to experienced surgeons. There are many scoring systems employed by surgeons to reduce the percentage of negative appendicectomies. One such example is the Alvarado system. The aim of our study was to evaluate the usefulness of the Alvarado scoring system in reducing the percentage of negative appendicectomies at Queen’s Hospital, a small district general hospital in England.
Case description
A 6-month cross-sectional study was carried out. Patients who were 16 years old or younger with a preliminary diagnosis of acute appendicitis were included in the study and their Alvarado score calculated. On the basis of their individual Alvarado score, they were placed in one of two groups: Group A (Alvarado score <6) and Group B (Alvarado score ≥6). The signs, symptoms, laboratory values, surgical interventions and histopathological reports, the gold standard for diagnosis of acute appendicitis, were then evaluated. The reliability of Alvarado scoring system was assessed by calculating the rate of negative appendicectomies which we defined as patients showing no signs of appendiceal inflammation on histopathology of the surgically removed appendix.
Results and Conclusions
26 patients (21 males, 5 females) were included in the study. They comprised 9 patients in Group A (34.6%) and 17 patients in Group B (65.4%). The largest age group was represented by 10-15 year olds (n=16, 61.5%). The symptoms at presentation included right iliac fossa pain (92.3%), nausea or vomiting (76.9%) and anorexia (73.1%). Clinical examination revealed tenderness in the right iliac fossa in all patients (100%), rebound tenderness in 16 cases (61.5%) and elevated temperature in 3 cases (11.5%). Laboratory analysis showed raised total leukocyte count in 12 cases (46.2%) with neutrophilia in 10 cases (38.5%). Of the 26 cases, 84.6% (n=22) were confirmed to have inflamed appendix by the surgeon performing the appendicectomy at the time of surgery. However, final diagnosis of inflamed appendix based on histopathology reports were confirmed in 19 cases (73.1%). The overall negative appendicectomy rate was therefore 26.9% (7 cases). The rate of negative appendicectomies in males and females were 15.4% and 11.5% respectively. The negative appendicectomy rate in Group A and B were 33.3% and 17.6% respectively. Sensitivity and specificity of Alvarado score in our study were 82% and 100% respectively.
Take home message
Regarding, the reliability of the Alvarado scoring system, our recommendations are:
(1) false negatives are few especially in high Alvarado scores (9 or greater);
(2) further investigations may be employed in low scores (<6) where the number of false negati
{"title":"The Alvarado scoring system in acute appendicitis: A 6-month cross-sectional study to evaluate its reliability in reducing the rate of negative appendicectomy at Queen’s Hospital, Burton","authors":"Joshua Agilinko *, Naseem Waraich","doi":"10.1016/j.nhccr.2017.10.031","DOIUrl":"10.1016/j.nhccr.2017.10.031","url":null,"abstract":"<div><h3>Introduction</h3><p>Globally, acute appendicitis is the most common paediatric intra-abdominal surgical emergency. The variations at presentation and the lack of a single reliable test to aid diagnosis may pose challenges to experienced surgeons. There are many scoring systems employed by surgeons to reduce the percentage of negative appendicectomies. One such example is the Alvarado system. The aim of our study was to evaluate the usefulness of the Alvarado scoring system in reducing the percentage of negative appendicectomies at Queen’s Hospital, a small district general hospital in England.</p></div><div><h3>Case description</h3><p>A 6-month cross-sectional study was carried out. Patients who were 16 years old or younger with a preliminary diagnosis of acute appendicitis were included in the study and their Alvarado score calculated. On the basis of their individual Alvarado score, they were placed in one of two groups: Group A (Alvarado score <6) and Group B (Alvarado score ≥6). The signs, symptoms, laboratory values, surgical interventions and histopathological reports, the gold standard for diagnosis of acute appendicitis, were then evaluated. The reliability of Alvarado scoring system was assessed by calculating the rate of negative appendicectomies which we defined as patients showing no signs of appendiceal inflammation on histopathology of the surgically removed appendix.</p></div><div><h3>Results and Conclusions</h3><p>26 patients (21 males, 5 females) were included in the study. They comprised 9 patients in Group A (34.6%) and 17 patients in Group B (65.4%). The largest age group was represented by 10-15 year olds (n=16, 61.5%). The symptoms at presentation included right iliac fossa pain (92.3%), nausea or vomiting (76.9%) and anorexia (73.1%). Clinical examination revealed tenderness in the right iliac fossa in all patients (100%), rebound tenderness in 16 cases (61.5%) and elevated temperature in 3 cases (11.5%). Laboratory analysis showed raised total leukocyte count in 12 cases (46.2%) with neutrophilia in 10 cases (38.5%). Of the 26 cases, 84.6% (n=22) were confirmed to have inflamed appendix by the surgeon performing the appendicectomy at the time of surgery. However, final diagnosis of inflamed appendix based on histopathology reports were confirmed in 19 cases (73.1%). The overall negative appendicectomy rate was therefore 26.9% (7 cases). The rate of negative appendicectomies in males and females were 15.4% and 11.5% respectively. The negative appendicectomy rate in Group A and B were 33.3% and 17.6% respectively. Sensitivity and specificity of Alvarado score in our study were 82% and 100% respectively.</p></div><div><h3>Take home message</h3><p>Regarding, the reliability of the Alvarado scoring system, our recommendations are:</p><p>(1) false negatives are few especially in high Alvarado scores (9 or greater);</p><p>(2) further investigations may be employed in low scores (<6) where the number of false negati","PeriodicalId":100954,"journal":{"name":"New Horizons in Clinical Case Reports","volume":"2 ","pages":"Page 32"},"PeriodicalIF":0.0,"publicationDate":"2017-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1016/j.nhccr.2017.10.031","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"89151189","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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