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      WSES Jerusalem guidelines for diagnosis and treatment of acute appendicitis

      , , , , , , , , , , , , , , , , , , , , , , ,   , , , , , , , , , , , , , , , , , , , , , ,

      World Journal of Emergency Surgery : WJES

      BioMed Central

      Acute Appendicitis, Guidelines, Consensus Conference, Alvarado Score, Appendicitis diagnosis score, Non-operative management, Antibiotics, Complicated appendicitis, Appendectomy, Laparoscopic appendectomy, Phlegmon, Appendiceal abscess

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          Abstract

          Acute appendicitis (AA) is among the most common cause of acute abdominal pain. Diagnosis of AA is challenging; a variable combination of clinical signs and symptoms has been used together with laboratory findings in several scoring systems proposed for suggesting the probability of AA and the possible subsequent management pathway. The role of imaging in the diagnosis of AA is still debated, with variable use of US, CT and MRI in different settings worldwide. Up to date, comprehensive clinical guidelines for diagnosis and management of AA have never been issued. In July 2015, during the 3rd World Congress of the WSES, held in Jerusalem (Israel), a panel of experts including an Organizational Committee and Scientific Committee and Scientific Secretariat, participated to a Consensus Conference where eight panelists presented a number of statements developed for each of the eight main questions about diagnosis and management of AA. The statements were then voted, eventually modified and finally approved by the participants to The Consensus Conference and lately by the board of co-authors. The current paper is reporting the definitive Guidelines Statements on each of the following topics: 1) Diagnostic efficiency of clinical scoring systems, 2) Role of Imaging, 3) Non-operative treatment for uncomplicated appendicitis, 4) Timing of appendectomy and in-hospital delay, 5) Surgical treatment 6) Scoring systems for intra-operative grading of appendicitis and their clinical usefulness 7) Non-surgical treatment for complicated appendicitis: abscess or phlegmon 8) Pre-operative and post-operative antibiotics.

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          Most cited references 154

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          The epidemiology of appendicitis and appendectomy in the United States.

          To describe the epidemiology of appendicitis and appendectomy in the United States, the authors analyzed National Hospital Discharge Survey data for the years 1979-1984. Approximately 250,000 cases of appendicitis occurred annually in the United States during this period, accounting for an estimated 1 million hospital days per year. The highest incidence of primary positive appendectomy (appendicitis) was found in persons aged 10-19 years (23.3 per 10,000 population per year); males had higher rates of appendicitis than females for all age groups (overall rate ratio, 1.4:1). Racial, geographic, and seasonal differences were also noted. Appendicitis rates were 1.5 times higher for whites than for nonwhites, highest (15.4 per 10,000 population per year) in the west north central region, and 11.3% higher in the summer than in the winter months. The highest rate of incidental appendectomy was found in women aged 35-44 years (43.8 per 10,000 population per year), 12.1 times higher than the rate for men of the same age. Between 1970 and 1984, the incidence of appendicitis decreased by 14.6%; reasons for this decline are unknown. A life table model suggests that the lifetime risk of appendicitis is 8.6% for males and 6.7% for females; the lifetime risk of appendectomy is 12.0% for males and 23.1% for females. Overall, an estimated 36 incidental procedures are performed to prevent one case of appendicitis; for the elderly, the preventive value of an incidental procedure is considerably lower.
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            A practical score for the early diagnosis of acute appendicitis.

            We conducted a retrospective study of 305 patients hospitalized with abdominal pain suggestive of acute appendicitis. Signs, symptoms, and laboratory findings were analyzed for specificity, sensitivity, predictive value, and joint probability. The total joint probability, the sum of a true-positive and a true-negative result, was chosen as a diagnostic weight indicative of the accuracy of the test. Eight predictive factors were found to be useful in making the diagnosis of acute appendicitis. Their importance, according to their diagnostic weight, was determined as follows: localized tenderness in the right lower quadrant, leukocytosis, migration of pain, shift to the left, temperature elevation, nausea-vomiting, anorexia-acetone, and direct rebound pain. Based on this weight, we devised a practical diagnostic score that may help in interpreting the confusing picture of acute appendicitis.
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              Acute appendicitis: modern understanding of pathogenesis, diagnosis, and management.

              Acute appendicitis is one of the most common abdominal emergencies worldwide. The cause remains poorly understood, with few advances in the past few decades. To obtain a confident preoperative diagnosis is still a challenge, since the possibility of appendicitis must be entertained in any patient presenting with an acute abdomen. Although biomarkers and imaging are valuable adjuncts to history and examination, their limitations mean that clinical assessment is still the mainstay of diagnosis. A clinical classification is used to stratify management based on simple (non-perforated) and complex (gangrenous or perforated) inflammation, although many patients remain with an equivocal diagnosis, which is one of the most challenging dilemmas. An observed divide in disease course suggests that some cases of simple appendicitis might be self-limiting or respond to antibiotics alone, whereas another type often seems to perforate before the patient reaches hospital. Although the mortality rate is low, postoperative complications are common in complex disease. We discuss existing knowledge in pathogenesis, modern diagnosis, and evolving strategies in management that are leading to stratified care for patients.
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                Author and article information

                Contributors
                salo75@inwind.it , salomone.disaverio@gmail.com
                arianna.birindelli@gmail.com
                mk@mdkelly.com
                faustocatena@gmail.com
                dweber@bigpond.net.au
                massimosartelli@gmail.com
                michael.Sugrue@hse.ie
                MDEMOYA@mgh.harvard.edu
                caxiaogomes@gmail.com
                aneelbhangu@doctors.org.uk
                fagresta@libero.it
                Ernest.Moore@dhha.org
                ksoreide@me.com
                Ewen.Griffiths@uhb.nhs.uk
                stevedecastro@gmail.com
                jeffrykashuk@gmail.com
                y_kluger@rambam.health.gov.il
                Ari.Leppaniemi@hus.fi
                lansaloni@hpg23.it
                anderssonmanne@gmail.com
                federico.coccolini@gmail.com
                rcoimbra@ucsd.edu
                k.gurusamy@ucl.ac.uk
                fc.campanile@gmail.com
                walt@biffl.com
                ochiara@yahoo.com
                FAMoore@tmhs.org
                peitzmanab@upmc.edu
                fragagp2008@gmail.com
                dcostacir@gmail.com
                ronmaier@uw.edu
                rizolis@smh.ca
                zsolt.balogh@hnehealth.nsw.gov.au
                Cino.Bendinelli@hnehealth.nsw.gov.au
                cirocchiroberto@yahoo.it
                valeria.tonini@unibo.it
                alice.piccinini2@studio.unibo.it
                gregorio.tugnoli@ausl.bologna.it
                Elio.jovine@gmail.com
                rpersiani@rm.unicatt.it
                abiondi@unict.it
                tscalea@umm.edu
                philip.stahel@dhha.org
                raoivatury@gmail.com
                gvelmahos@partners.org
                rolandersson@gmail.com
                Journal
                World J Emerg Surg
                World J Emerg Surg
                World Journal of Emergency Surgery : WJES
                BioMed Central (London )
                1749-7922
                18 July 2016
                18 July 2016
                2016
                : 11
                Affiliations
                [ ]Emergency and Trauma Surgery – Maggiore Hospital, AUSL, Bologna, Italy
                [ ]S. Orsola Malpighi University Hospital – University of Bologna, Bologna, Italy
                [ ]Locum Surgeon, Acute Surgical Unit, Canberra Hospital, Canberra, ACT Australia
                [ ]Emergency and Trauma Surgery Department, Maggiore Hospital of Parma, Parma, Italy
                [ ]Trauma and General Surgeon Royal Perth Hospital & The University of Western Australia, Perth, Australia
                [ ]Macerata Hospital, Macerata, Italy
                [ ]Letterkenny Hospital, Donegal, Ireland
                [ ]Harvard Medical School - Massachusetts General Hospital, Boston, USA
                [ ]Department of Surgery Hospital Universitario, Universidade General de Juiz de Fora, Juiz de Fora, Brazil
                [ ]Academic Department of Surgery, University Hospitals Birmingham NHS Foundation Trust, Edgabaston, Birmingham, UK
                [ ]General Surgery, Civil Hospital - ULSS19, Veneto, Adria, RO Italy
                [ ]Denver Health System – Denver Health Medical Center, Denver, USA
                [ ]Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway
                [ ]University Hospitals Birmingham NHS Foundation Trust Queen Elizabeth Hospital, Birmingham, UK
                [ ]Department of Surgery, OLVG, Amsterdam, The Netherlands
                [ ]Department of Surgery, University of Jerusalem, Jerusalem, Israel
                [ ]Division of General Surgery, Rambam Health Care Campus, Haifa, Israel
                [ ]Abdominal Center, University of Helsinki, Helsinki, Finland
                [ ]General Surgery I, Papa Giovanni XXIII Hospital, Bergamo, Italy
                [ ]Department of Surgery, Linkoping University, Linkoping, Sweden
                [ ]UCSD Health System - Hillcrest Campus Department of Surgery Chief Division of Trauma, Surgical Critical Care, Burns, and Acute Care Surgery, San Diego, CA USA
                [ ]Royal Free Campus, University College London, London, UK
                [ ]Department of Surgery, San Giovanni Decollato Andosilla Hospital, Viterbo, Italy
                [ ]Queen’s Medical Center, University of Hawaii, Honolulu, HI USA
                [ ]Niguarda Hospital, Milan, Italy
                [ ]University of Florida, Gainesville, USA
                [ ]Department of Surgery, University of Pittsburgh School of Medicine, UPMC-Presbyterian, Pittsburgh, USA
                [ ]Faculdade de Ciências Médicas (FCM) - Unicamp, Campinas, SP Brazil
                [ ]Alicante, Spain
                [ ]Department of Surgery, University of Washington, Harborview Medical Center, Seattle, WA USA
                [ ]St. Michael Hospital, Toronto, Canada
                [ ]Department of Traumatology, John Hunter Hospital and University of Newcastle, Newcastle, NSW Australia
                [ ]Department of Surgery, Terni Hospital, University of Perugia, Terni, Italy
                [ ]Trauma Surgery Unit - Maggiore Hospital AUSL, Bologna, Italy
                [ ]Department of Surgery, Maggiore Hospital AUSL, Bologna, Italy
                [ ]Catholic University, A. Gemelli University Hospital, Rome, Italy
                [ ]Department of Surgery, University of Catania, Catania, Italy
                [ ]R. Adams Cowley Trauma Center, Baltimore, MD USA
                [ ]Professor Emeritus Virginia Commonwealth University, Richmond, VA USA
                [ ]Harvard Medical School - Chief of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Boston, USA
                Article
                90
                10.1186/s13017-016-0090-5
                4949879
                27437029
                © The Author(s). 2016

                Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

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