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We report a case of a female patient with a picture of "atypical appendicitis," with 3 days of abdominal pain, localized to the right lower quadrant with no nausea, vomiting, diarrhea, or anorexia. On examination she was febrile to 38.4 degrees C, had tenderness at McBurney's point, and a leukocyte count of 11,200. A computerized axial tomography (CAT) scan was obtained showing changes consistent with appendicitis. On laparoscopic exploration the patient was found to have cecal masses. Definitive surgical treatment was deferred until after adequate evaluation of the colon. Postoperative colonoscopy demonstrated cecal diverticulitis. Management of cecal diverticulitis found during laparotomy for presumed appendicitis has included right hemicolectomy, ileocolic resection or appendectomy, and conservative treatment with antibiotics. The laparoscopic approach in a patient with an equivocal history and physical examination allows for definitive workup of inflammatory cecal masses found during surgery for appendicitis.
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PMID:Cecal diverticulitis: a case report and review of the current literature. 1199 78

The authors present a diagnostically difficult case of a three year old girl with abdominal pain. The girl with abdominal pains, nausea, upper airways infarction and some urinary system symptoms was admitted to Children's Surgical Clinic for observation. She was given antibiotic therapy and i.v. infusions. WBC was 29.6 tys./ul and CRP 2.7 mg/dl. No other abnormalities were detected in biochemical or sonographic investigation. The girl was submitted to laparotomy because of unclear abdominal signs suggesting acute appendicitis. Phlegmonous appendicitis and twisted/rotated left ovary with multiple adhesions were found. Histopathological investigation showed teratoma of the left ovary. Postoperative course went without complication.
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PMID:[Rare coexistence of phlegmonous appendicitis and tumor of a twisted left ovary]. 1291 74

Vomiting or its lesser stages-anorexia, nausea-is a prime symptom of the most serious surgically curable diseases of childhood. In the newborn, when vomitus is green, abdomen scaphoid, and erect roentgen view shows air-fluid levels in stomach and duodenum with gas beyond, partial duodenal obstruction is present and midgut volvulus with malrotation is likely enough to justify immediate exploration. In infancy, vomiting is a clear sign of intussusception when associated with intermittent colicky pain, palpable mass and "currant-jelly" feces. These symptoms are not always present, and if there is blood in the feces, barium enema study must follow. In further doubt, exploration may be justified. In childhood, a common early symptom of appendicitis is vomiting accompanied by pain without any complete remission. Constipation is frequent but diarrhea may occur and contribute to an impression of gastroenteritis. Complete and repeated physical examination, with a history of the above symptoms, should lead to correct diagnosis.
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PMID:Vomiting as a symptom of serious disease in infants and children. 1382 64

In fifteen cases of amebiasis masquerading as appendicitis, the important findings were nausea, vomiting, epigastric pain, pain in the right lower quadrant of the abdomen, fever, and leukocytosis. Amebiasis ought to be considered and appropriate studies carried out in differential diagnosis of cases in which symptoms indicate acute, subacute or "chronic" appendicitis. Depending on indications, the studies should include radiography with barium enema, sigmoidoscopy, complement fixation test, a minimum of nine stool examinations, a stool culture, and examination of purged stools unless this is contraindicated.
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PMID:Amebiasis masquerading as appendicitis. 1479 77

The aim of our study was to further improve the preoperative diagnosis of acute appendicitis in children and adolescents. All diagnostic parameters from the patients' medical history (duration and quality of abdominal pain, stool behaviour), the laboratory (leukocytes, C-reactive protein), the clinic (defense, tenderness on percussion, nausea, vomiting, dry tongue) and repeated ultrasound investigations (visualisation of the appendix, indirect signs of an inflammatory process in the appendix region) were documented prospectively and were re-assessed with regard to their diagnostic value. As an additional parameter, procalcitonin was determined. 1156 patients (593 male/563 female) with a mean age of 9.51 years (+/- 1.2 yrs) (max. 15 yrs/min. 2.3 yrs), referred to the department with acute abdominal pain, were examined. 233 (141 male/92 female; 20.1 %) of these patients with a mean age of 10.47 years (+/- 1.1 yr) had appendicitis. Based on the patients' medical history, laboratory findings, the initial clinical investigation and the initial ultrasound investigation, 173 patients (74.3 % of the later operated 233 children with appendicitis) were diagnosed with certainty. The diagnosis of 60 patients (25.7 %) of this group remained uncertain. These patients received a saline enema (Clysmol, Pharmacia & Upjohn Company) and were subjected to a second clinical and sonographic investigation after approximately four hours of parenteral fluid substitution (Ringer's lactate, Mayrhofer Pharmazeutika Company, 4 ml/kg/h). The other 923 patients (79.83 %) were discharged and were followed up as outpatients in the following days. Based on this stepwise procedure, the percentage of correctly diagnosed appendicitis could be increased to 97.4 %. The measurement of procalcitonin proved to be of no value in the diagnosis of acute appendicitis. It may be concluded that in children with abdominal pain, high diagnostic accuracy can only be achieved by a carefully combined evaluation of all individual diagnostic parameters and repeated investigations.
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PMID:Advancements in the diagnosis of acute appendicitis in children and adolescents. 1563 Jun 42

Paratubal cyst can undergo torsion that can make it difficult to diagnose since tubal cysts mimic ovarian cysts. Most reported cases of paratubal cysts have occurred in pediatric patients, and this type of cyst rarely causes symptoms of lower abdominal pain mimicking appendicitis. We present the case of a 28-year-old female who was taking Carbergoline for hyperprolactinoma associated with a pituitary adenoma who came to the ER at Henry Ford Hospital in Detroit experiencing severe abdominal pain. Her pain was not accompanied by nausea, vomiting or other gastrointestinal symptoms. A transvaginal ultrasound revealed a normal uterus with the right ovary containing a cyst measuring 3 cm. x 2 cm. She was released on analgesics and seen at the clinic at Henry Ford Hospital three days later. She was still experiencing pain and was given antibiotics and Darvocet. When the pain had not subsided 48 hours later, a decision was made to perform diagnostic laparoscopy. Surgery was performed 10 days later and a paratubal cyst was removed that was twisted twice on its pedicle. This case illustrates the fact that torsion of paratubal cyst should be included in the differential diagnosis of adnexal pain.
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PMID:Paratubal cyst: a case report. 1629

Mesenteric inflammatory veno-occlusive disease (MIVOD) is a relatively recently known and not very often diagnosed form of ischemic bowel disease of low incidence und unknown etiology. We present the case of a patient who after presentation of inconclusive signs of epigastric pain and rectal bleeding suddenly developed right abdominal pain with local peritonism. Suspecting intestinal ischemia or perforated appendicitis we first performed laparoscopy, which showed an inflammable tumor of cecum, ascending colon and appendix with massive adhesions to the abdominal wall. We performed an open right hemicolectomy with primary anastomosis. The patient developed a deep vein thrombosis of the vena tibialis post. and vena saphena parva. After 12 months our patient is free of complaints and recurrence. Investigations carried out showed no evidence of hypercoagulopathy. The presentation of MIVOD can range from chronic inflammatory bowel disease with recurrent abdominal pain in combination with nausea, emesis and bloody diarrhea to acute abdomen. Therefore diagnostic misinterpretation and mistherapy as well as underdiagnosis is common. Histologic investigation shows a variable inflammatory infiltration of multiple veins of the intestinal wall and the mesentery as well as thrombotic vessel occlusion in different stages without involvement of the arteries. All forms of hypercoagulopathy, parasitic disease, sepsis and malignancy have to be excluded. Therapeutic success can only be achieved with surgical resection of the affected bowel, whereon in general no recurrence will occur.
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PMID:[Mesenteric inflammatory veno-occlusive disease (MIVOD)--a rare cause of intestinal ischemia]. 1639 91

Appendectomy for appendicitis is one of the most common procedures performed in the United States. Residual tissue left after an initial appendectomy risks the development of stump appendicitis. A comprehensive review of the English-language literature revealed 36 reported cases of stump appendicitis. Typically, patients present with signs and symptoms similar to acute appendicitis; however, due to prior surgery, the diagnosis is difficult and the rate of appendiceal stump perforation is extremely high. Herein, we present a case of a 32-year-old female presenting with right lower quadrant pain, nausea, and fever 5 months after laparoscopic appendectomy. Upon surgery, an appendiceal stump was discovered.
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PMID:Stump appendicitis: a comprehensive review of literature. 1653 49

Appendicitis has rarely been reported following solid organ transplantation and never following liver transplantation. We reviewed records of all patients who received solid organ transplants at UCLA between 1989 and 2002 and subsequently underwent appendectomy for presumed acute appendicitis. Of nearly 8000 transplant patients, 17 (nine male, eight female) subsequently underwent appendectomy for presumed acute appendicitis. Average age at appendectomy was 37 yrs (range 6-73 yrs). Organ transplants included liver (seven patients), heart (four), kidney (three), kidney-pancreas (two), and heart-kidney (one). The mean interval from transplant to appendectomy was 1064 d (16-2977). Presenting symptoms and signs included abdominal pain in 16 patients (94%); nausea and or vomiting in 15 (88%); right lower quadrant tenderness in 16; and leukocytosis (WBC > 10 000) in 13 (76%). Mean interval from presentation to appendectomy was 0.94 d (range 0-4). Computed tomography (CT) was performed in 16 patients and showed signs of acute appendicitis in 15. Open technique was used in all patients, preceded by laparoscopy in one. Pathology showed appendicitis in 15 patients (one with perforation), serositis in one, and a normal appendix in one. Mean duration of hospitalization was 7 d (range 1-20). Complications occurred in four patients (24%) and included intra-abdominal abscess requiring percutaneous drainage, ventral hernia, small bowel obstruction, and hematuria in one patient each. There were no deaths and no cases of acute rejection during hospitalization. Average length of follow-up was 712 d (range 3-2492). We conclude that appendicitis is relatively rare following solid organ transplantation. CT facilitates prompt diagnosis. The clinical presentation is similar to that of non-transplant patients, but complications are more frequent, and hospitalization is longer.
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PMID:Acute appendicitis after solid organ transplantation. 1655 58

A Meckel diverticulum is an embryonic remnant of the omphalomesenteric duct that occurs in approximately 2% of the population. Most are asymptomatic; however, they are vulnerable to inflammation with subsequent consequences including diverticulitis and perforation. We report an 11-year-old boy who underwent laparoscopic appendectomy for perforated appendicitis at an outside institution. During his convalescence he underwent percutaneous drainage of a presumed postoperative abscess. A follow-up drain study demonstrated an enteric fistula. The drain was slowly removed from the abdomen over a period of 1 week. Three weeks following drain removal the patient reported recurrent nausea and abdominal pain. A CT scan demonstrated a 3.7-cm rim-enhancing air-fluid level with dependent contrast consistent with persistent enteric fistula and abscess. Exploratory laparoscopy was performed, at which time a Meckel diverticulum was identified and resected. This case highlights the diagnostic challenge and limitations of conventional radiology in complicated Meckel diverticulum.
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PMID:Presumed appendiceal abscess discovered to be ruptured Meckel diverticulum following percutaneous drainage. 1849 Oct 85


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