Intususcepción intestinal en el contexto de una apendicitis aguda / Intestinal intussusception in the context of acute appendicitis: a case report and lit-erature review

Introducción: La intususcepción es una patología abdominal idiopá-tica o secundaria a procesos intesti-nales que actúan como puntos de partida para la invaginación. Se han descrito casos de arrastre de estruc-turas que derivan en otros procesos inflamatorios como la apendicitis aguda. Caso clínico: Niño 3 años, con dolor abdominal de 6 horas de evolución. Al examen físico se pre-senta pálido, somnoliento, taqui-cárdico y deshidratado. El abdo-men con signos apendiculares posi-tivos, con palpación en masa en fosa iliaca derecha. Taller diagnóstico: Leucocitos 9690 u/mm3, neutrófilos 58.1%. Ecografía con imagen sugerente de intususcepción intestinal con cam-bios inflamatorios en la grasa me-sentérica. Se realiza tomografía abdominal que reporta intususcep-ción ileocolónica de 47 x 50 mm, con múltiples ganglios reactivos mesentéricos, con imagen apendicu-lar en dirección pélvica, con apendi-colito en su interior. Evolución: El manejo quirúrgico incluyó una laparotomía explorato-ria con desinvaginación manual y apendicectomía convencional. El reporte de patología fue apendicitis aguda supurativa. El paciente 48 horas hospitalizado, recibió Ampici-lina + Sulbactam y analgesia. Al mejorar la función abdominal fue dado de alta. Conclusiones: En este caso la apendicitis aguda fue la causa de intususección intestinal con el signo ecográfico de la "diana" en un paciente de 3 años de edad.

Introduction: Intussusception is an idiopathic abdominal pathology or secondary to intestinal processes that act as starting points for intussusception. Cases of dragging of structures that lead to other inflammatory processes, such as acute appendicitis, have been described. Clinical case: 3-year-old boy with abdominal pain of 6 hours of evolution. On physical examination, he appears pale, drowsy, tachycardic, and dehydrated. The abdomen with positive appendiceal signs, with palpation of a mass in the right iliac fossa. Diagnostic workshop: leukocytes 9690 u/mm3, neutrophils 58.1%. Ultrasound with image suggestive of intestinal intussusception with inflammatory changes in the mesenteric fat. An abdominal tomography was performed that reported ileocolonic intussusception of 47 x 50 mm, with multiple mesenteric reactive nodes, an appendicular image in the pelvic direction, and an appendicolith inside. Evolution: Surgical management included an exploratory laparotomy with manual evagination and conventional appendectomy. The pathology report was acute suppurative appendicitis. The patient was hospitalized for 48 hours and received Ampicillin + Sulbac-tam and analgesia. When abdominal function improved, he was discharged. Conclusions: In this case, acute appendicitis was the cause of intestinal intussusception with the ultrasound sign of the "target" in a 3-year-old patient.

Estudio de los desenlaces perioperatorios de la apendicitis aguda durante la pandemia por COVID-19: un estudio observacional analítico de cohorte / Study of perioperative outcomes of acute appendicitis during the COVID-19 pandemic: An analytical observational cohort study

Introducción. La condición de pandemia por COVID-19 impactó a la sociedad y los sistemas de salud a nivel mundial. Las adaptaciones institucionales procuraron mantener la calidad de la atención a pesar de un contexto organizacional desfavorable. La apendicitis aguda requirió ser manejada en un nuevo escenario institucional. El objetivo de este estudio fue evaluar la efectividad del tratamiento quirúrgico de la apendicitis durante la pandemia. Métodos. Estudio observacional analítico, retrospectivo, en el que se incluyeron pacientes sometidos a apendicectomía, antes y durante la pandemia por COVID-19. Se evaluaron las complicaciones, infección del sitio operatorio, reingresos y estancia hospitalaria. Adicionalmente, se analizaron los desenlaces en los 3 picos epidemiológicos de la pandemia. Se efectuaron estadísticas descriptivas y analíticas entre los grupos a comparar. Resultados. Se incluyeron 1521 pacientes con apendicitis, 48,3 % operados antes y 51,7 % durante la pandemia. No hubo diferencias entre los grupos en complicaciones (p=0,352), infección del sitio operatorio (p=0,191), reingreso en los primeros 30 días (p=0,605) y estancia hospitalaria (p=0,514). El manejo de la apendicitis durante el tercer pico fue similar a las prácticas habituales. El tiempo de evolución fue mayor durante la pandemia (p=0,04) y los pacientes fueron llevados a cirugía más pronto que previo a la pandemia (p<0,001). Conclusiones. No se evidenció un incremento de complicaciones quirúrgicas, reingresos, estancia hospitalaria ni infección del sitio operatorio en los pacientes operados durante la pandemia. Hubo un efecto favorable para los pacientes como consecuencia de la adaptación institucional en la pandemia por COVID-19

Introduction. COVID-19 pandemic impacted society and health systems worldwide. The institutional adaptations sought to maintain the quality of care in an unfavorable organizational context. Acute appendicitis was required to be managed in a new institutional setting. The effectiveness of surgical treatment of appendicitis during the pandemic was evaluated. Methods. Retrospective analytical observational study, in patients with appendectomy, before and during COVID-19 pandemic. Complications, surgical site infections, readmissions, and hospital stay were evaluated. Additionally, the outcomes in the 3 epidemiological peaks of the pandemic were analyzed. Descriptive and analytical statistics were performed between the groups to be compared. Results. A total of 1521 patients with appendicitis were included, 48.3% before and 51.7% during the pandemic. There were no differences in complications (p=0.352), operative site infection (p=0.191), readmission at 30 days (p=0.605), and hospital stay (p=0.514) between the groups. Management of appendicitis during the 3rd peak was like usual practices. There was a long evolution time during the pandemic (p=0.04) and the patients were taken to surgery sooner than before the pandemic (p<0.001). Conclusions. There was no evidence of an increase in surgical complications, readmissions, hospital stay, and surgical site infections during patients who underwent surgery. There was a favorable effect for patients because of institutional adaptation in the COVID-19 pandemic

Apendicitis aguda durante la pandemia de COVID-19: experiencia en un centro de alta complejidad en Boyacá, Colombia / Acute appendicitis during the COVID-19 pandemic: Experience in a high-level complex center in Boyacá, Colombia

Introducción. La pandemia de COVID-19 replanteó la forma de atención en los sistemas de salud, afectando todas aquellas patologías no relacionadas con infecciones respiratorias, como la apendicitis aguda. El miedo al contagio por SARS-CoV-2 y las medidas restrictivas a la movilidad pudieron aumentar el tiempo desde el inicio de los síntomas hasta la consulta al servicio de urgencias, derivando en complicaciones intra y posoperatorias. Métodos. Estudio observacional descriptivo de corte trasversal y retrospectivo, donde se incluyeron todos los pacientes diagnosticados con apendicitis aguda llevados a apendicectomía, que fueron divididos en dos grupos, considerados prepandemia, desde el 1° de septiembre de 2018 al 15 de marzo de 2020, y pandemia, desde el 16 de marzo de 2020 al 30 de septiembre de 2021. Resultados. Fueron identificados 1000 pacientes, distribuidos en 501 pacientes en el grupo prepandemia y 499 en el grupo pandemia. El promedio de tiempo de consulta desde el momento de inicio de síntomas hasta consulta fue de 43 horas en el grupo prepandemia y de casi 45 horas en el grupo pandemia. Discusión. A pesar de las restricciones por la enfermedad causada por el nuevo coronavirus y el miedo que puede existir por el contagio, en nuestro centro no se evidenció un cambio en el manejo y presentación de los pacientes diagnosticados con apendicitis aguda

Introduction. The COVID-19 pandemic varied the way health systems were attended, thus affecting pathologies not related to respiratory infections, such as acute appendicitis. Fear of SARS-CoV-2 infection and mobility restrictive measures may have implied a longer time from the onset of symptoms to consultation of the emergency department, leading to intraoperative and postoperative complications. Methods. Retrospective cross-sectional descriptive observational study, identifying all patients diagnosed with acute appendicitis and taken for appendectomy, divided into two groups, considered pre-pandemic, from September 1, 2018 to March 15, 2020, and pandemic, from March 16, 2020 to September 30, 2021. Results. One-thousand patients were identified, 501 patients were distributed in the pre-pandemic group and 499 in the pandemic group. The average consultation time from the time of onset of symptoms to consultation was 43 hours in the prepandemic group and almost 45 hours in the pandemic. Discussion. Despite the restrictions due to the disease caused by the new coronavirus and the fear that may existed due to contagion, in our center there was no evidence of a change in the management and presentation of patients diagnosed with acute appendicitis

Comparación de la seguridad y la eficacia del uso de antibióticos frente a la apendicectomía en el tratamiento de la apendicitis no complicada en adultos. Revisión sistemática y metaanálisis / Comparison of safety and effectiveness of the use of antibiotics versus appendectomy in the management of uncomplicated appendicitis in adults. Systematic review and metanalysis

Introducción. La apendicitis aguda es una emergencia quirúrgica frecuente, en la cual el tratamiento de tipo conservador basado en antibióticos se ha identificado como una opción terapéutica que necesita seguir siendo estudiada. El objetivo de este estudio fue determinar las diferencias en seguridad y eficacia del uso de antibióticos en comparación con la apendicectomía en adultos con apendicitis no complicada. Métodos. Revisión sistemática y metaanálisis. Se encontraron 452 estudios; después de una selección, 45 se evaluaron en texto completo y 15 para calidad metodológica; 11 estudios fueron seleccionados y 9 incluidos en el metaanálisis. Resultados. Se contó con 3186 participantes, de los cuales 1512 fueron tratados con terapia antibiótica y 1674 sometidos a apendicectomía. Se identificó estancia hospitalaria más corta en los pacientes sometidos a apendicectomía (SMD: 0,28; IC95%: 0,14 a 0,41). Para los pacientes tratados con terapia antibiótica, se evidenció puntajes de riesgo menores en las escalas de diagnóstico de apendicitis (SMD: -0,13; IC95%: -0,22 a -0,04), menor éxito terapéutico en un 16 % (RR: 0,84; IC95%: 0,77 a 0,92) y reducción del riesgo de complicaciones del 63 % (RR: 0,37; IC95%: 0,25 a 0,53). Se encontró alta heterogeneidad y riesgo de sesgo de publicación. Conclusiones. La terapia antibiótica necesita mayor evidencia para desenlaces como calidad de vida, satisfacción, dolor, o complicaciones específicas, entre otros, que permitan hacer comparaciones más contundentes. Los pacientes que consideren el manejo conservador necesitan ser adecuadamente asesorados y monitorizados para optimizar sus posibilidades de resultados favorables y la oportuna identificación de complicaciones que necesiten de otros abordajes

Introduction. Acute appendicitis is a frequent surgical emergency, in which conservative antibiotic-based treatment has been identified as a therapeutic option that needs further study. The objective of this study is to determine the differences in safety and efficacy of the use of antibiotics compared to appendectomy in uncomplicated appendicitis in adults. Methods. Systematic review and meta-analysis; 452 studies were found; 45 were evaluated in full text, 15 were evaluated in methodological quality; 11 studies were selected and nine meta-analysed. Results. There were 3186 participants, of whom 1512 were treated with antibiotic therapy and 1674 underwent appendectomy. Shorter stays are identified in patients undergoing appendectomy (SMD: 0.28 CI 95% 0.14 to 0.41). It was evidenced for patients treated with antibiotic therapy lower risk scores in the appendicitis diagnostic scales (SMD: -0.13; CI 95%: -0.22 to -0.04), in 16% less therapeutic success (RR: 0.84; CI 95%: 0.77 to 0.92) and a reduction in the risk of complications of 63% (RR: 0.37, CI 95%: 0.25 to 0.53). High heterogeneity and risk of publication bias were reported.Conclusions. Antibiotic therapy needs more evidence for outcomes such as quality of life, satisfaction, pain, specific complications, among others; that allow for more compelling comparisons. Patients who consider the conservative approach need to be adequately advised and monitored to optimize their chances of favorable results and the timely identification of complications that require other approaches

Factores asociados a la duración de la estancia hospitalaria posterior a la apendicectomía laparoscópica / Factors associated with length of hospital stay after laparoscopic appendectomy

Introducción. El objetivo de este estudio fue determinar los factores asociados a la duración de la estancia hospitalaria posterior a una apendicectomía laparoscópica. Métodos. Se realizó un estudio observacional, analítico, retrospectivo, en el Hospital de Alta Complejidad "Virgen de la Puerta" en Trujillo, Perú, entre 2017 y 2019. La muestra de 78 pacientes se distribuyó en hospitalización prolongada (mayor de 3 días) y hospitalización corta (igual o menor a 3 días). Para el análisis bivariado se emplearon las pruebas t de Student y chi cuadrado y para el análisis multivariado se utilizó regresión logística múltiple. Resultados. No existe asociación entre el recuento de leucocitos y la duración de la hospitalización. El análisis multivariado determinó asociación significativa entre la estancia hospitalaria y las siguientes variables: edad (OR 1,051; p=0,027), tiempo quirúrgico (OR 1,028; p=0,013), diagnóstico quirúrgico de apendicitis complicada (OR 15,008; p=0,018), y sexo femenino (OR 6,079; p=0,010). Conclusión. Los factores asociados a la duración de la hospitalización posterior a apendicectomía laparoscópica en este grupo de pacientes fueron la edad, el tiempo quirúrgico, el diagnóstico quirúrgico de apendicitis complicada y el sexo femenino

Introduction. The objective of this study was to determine factors associated with length of hospital stay after laparoscopic appendectomy. Methods. An observational, analytical, retrospective study was carried out at the "Virgen de la Puerta" High Complexity Hospital in Trujillo, Peru, during the period 2017-2019. The sample of 78 patients was divided into prolonged hospitalization (>3 days) and short hospitalization (≤3 days). For the bivariate analysis, the Student's t-test and chi-square were used. Multiple logistic regression was used for multivariate analysis. Results. There is no association between leukocyte count and length of hospitalization. Multivariate analysis determined a significant association between hospital stay and the following variables: age (OR 1.051; p=0.027), surgical time (OR 1.028; p=0.013), surgical diagnosis of complicated appendicitis (OR 15.008; p=0.018), and female sex (OR 6.079; p=0.010). Conclusion. Factors associated with the duration of hospitalization after laparoscopic appendectomy in these patients were age, surgical time, surgical diagnosis of complicated appendicitis and female sex

Apéndice cecal invertida: hallazgos en colonoscopía / Inverted cecal appendix: colonoscopy findings

Introducción. El apéndice cecal invertido, inversión apendicular o intususcepción apendicular, corresponde a una condición anatómica descrita en 1859. La primera operación de invaginación apendicular se realizó en 1890, y desde entonces se han descrito diferentes técnicas quirúrgicas y endoscópicas para el tratamiento de esta alteración. Casos clínicos. Se presentandos casos de pacientes a quienes se les indicó colonoscopia como parte de estudio de dolor abdominal y diarrea y se identificó una intususcepción apendicular completa y apendicitis y una inversión del muñón apendicular. Resultados. Mediante la colonoscopia se hizo el diagnóstico de apendicitis aguda en una de las pacientes, quien presentaba inversión apendicular completa tipo 5, que fue tratada con manejo farmacológico y seguimiento clínico. En la otra paciente hubo un hallazgo incidental de inversión del muñón apendicular tipo 3. Conclusiones. Durante la realización de estudios colonoscópicos, se debe tener en cuenta el diagnóstico de intususcepción apendicular o apéndice invertido, para evitar intervenciones erróneas, como polipectomías, que generen riesgo potencial en los pacientes.

Introduction. Inverted cecal appendix, appendicular inversion or appendicular intussusception, corresponds to an anatomical condition described in 1859. The first appendicular invagination operation was performed in 1890, and since then different surgical and endoscopic techniques have been described for its treatment. Clinical cases. We present two patients who underwent colonoscopy as part of the study of abdominal pain and diarrhea and in whom were identified a complete appendicular intussusception and appendicitis, and an inversion of the appendicular stump. Results. Through colonoscopy, the diagnosis of acute appendicitis was made in one of the patients, who presented type 5 complete appendicular inversion, which was treated with pharmacological management and clinical follow-up. In the other patient, the incidental finding of inversion of the appendicular stump type 3 was made. Conclusions. During colonoscopy, the diagnosis of appendicular intussusception or inverted appendix must be taken into account to avoid erroneous interventions such as polypectomies that generate potential risk in patients.

Apendicitis aguda y el riesgo de tumor maligno oculto. Presentación de un caso y revisión sistemática de la literatura / Acute appendicitis and the risk of hidden malignant tumor. Presentation of a case and systematic review of literature

Introducción: Los tumores apendiculares representan aproximadamente 1% de los tumores malignos del intestino grueso. Más del 50% de las neoplasias primarias del apéndice se manifiestan inicialmente como apendicitis aguda. Métodos: Se reporta caso de paciente masculino que presentó adenocarcinoma invasor en biopsia de pieza quirúrgica de apéndice cecal tras apendicectomía, tomando la decisión de realizar hemicolectomía derecha laparoscópica diferida. Discusión: En este caso y como en la mayoría de los reportes de la bibliografía mundial, el adenocarcinoma simula un cuadro de AA. En un metaanálisis y una revisión sistemática de 2.771 pacientes diagnosticados de masa apendicular inflamatoria (flemón o absceso), Andersson et al. encontró 31 con tumores malignos. Estas lesiones se detectan en el 0,9% al 1,4% de las apendicectomías realizadas para tratar la AA. Conclusión: Este subtipo histológico presenta mayor incidencia de metástasis en los ganglios linfáticos y la supervivencia global era del 47,5%. Es por ello por lo que abogamos por la resección colónica como tratamiento definitivo del adenocarcinoma de apéndice cecal.

INTRODUCTION: Appendulular tumors represent approximately 1% of malignant tumors of the large intestine. More than 50% of the primary neoplasms of the appendix initially manifest as acute appendicitis. Methods: Men's patient who presented invading adenocarcinoma in Cecal Appendix Surgical Party Biopsy after appendectomy, making the decision to perform deferred laparoscopic right hemicolectomy, is reported. Discussion: In this case and as in most world literature reports, adenocarcinoma simulates an AA picture. In a meta -analysis and a systematic review of 2,771 diagnosed patients of inflammatory appendicular mass (phlegmon or abscess), Andersson et al. He found 31 with malignant tumors. These lesions are detected at 0.9% to 1.4% of appendectomies made to treat the AA. Conclusion: This histological subtype has a greater incidence of metastasis in lymph nodes and global survival was 47.5%. That is why we advocate colonic resection as a definitive treatment of cecal appendix adenocarcinoma.

Índice neutrófilos-linfocitos en el diagnóstico de apendicitis aguda. Una evaluación de su precisión diagnóstica / Neutrophil-to-lymphocyte ratio in the diagnosis of acute appendicitis. Assessment of its diagnostic accuracy

Introducción. La apendicitis aguda (AA) en pacientes pediátricos requiere de un diagnóstico certero. El índice neutrófilos-linfocitos (INL) es un parámetro accesible que puede ser útil en su diagnóstico. Objetivo. Determinar la precisión del INL para diagnosticar AA en pacientes con dolor abdominal. Población y métodos. Estudio de prueba diagnóstica. Se incluyeron 520 pacientes atendidos en el servicio de urgencias pediátricas. Para cuantificar la precisión diagnóstica, se estimó la sensibilidad, la especificidad, los valores predictivos (VP) y los cocientes de probabilidad (CP). Se utilizó un modelo de regresión logística múltiple para evaluar el efecto de las potenciales variables confusoras en la relación entre el INL y la AA. Resultados. La prevalencia de AA fue del 49 %. Para un punto de corte de 5, la sensibilidad fue del 85,1 %, especificidad: 78,9 %, VP+: 79,5 % y VP-: 84,6 %. Sin embargo, basándose en los cocientes de probabilidad, el INL es una prueba poco potente para el diagnóstico de AA (CP+ = 4,03 y CP- = 0,18) y resultó una prueba sin utilidad diagnóstica en el caso de apendicitis complicada (CP+ = 1,57 y CP- = 0,55). Después del ajuste por edad, sexo, obesidad, tiempo de evolución y uso de analgésicos, el INL fue una variable explicativa de la presencia de AA (odds ratio = 23,53; IC95 % 13,14-42,15). Conclusiones. El INL no es lo suficientemente preciso aisladamente para confirmar o descartar la presencia de AA. No obstante, el INL puede emplearse junto con otras pruebas para seleccionar a los pacientes en los cuales es necesario un mayor estudio.

Introduction. Acute appendicitis (AA) in pediatric patients requires an accurate diagnosis. The neutrophil-to-lymphocyte ratio (NLR) is an accessible parameter useful for its diagnosis. Objective. To determine NLR accuracy to diagnose AA in patients with abdominal pain. Population and methods. Diagnostic test study. A total of 520 patients seen at the Pediatric Emergency Department were included. Diagnostic accuracy was estimated based on sensitivity, specificity, predictive values, and likelihood ratios. A multiple logistic regression model was used to assess the effect of potentially confounding variables in the relationship between NLR and AA. Results. The prevalence of AA was 49%. For a cutoff point of 5, sensitivity was 85.1%, specificity: 78.9%; positive predictive value: 79.5%; and negative predictive value: 84.6%. However, based on likelihood ratios, the NLR is not powerful enough to diagnose AA (positive likelihood ratio = 4.03 and negative likelihood ratio = 0.18) and did not exhibit diagnostic usefulness in complicated appendicitis (positive likelihood ratio = 1.57 and negative likelihood ratio = 0.55). Following adjustment for age, sex, obesity, time since symptom onset, and analgesic use, the NLR was an explanatory variable for the presence of AA (odds ratio = 23.53; 95% confidence interval: 13.14­42.15). Conclusions. The NLR alone is not sufficiently accurate to confirm or rule out the presence of AA. However, the NLR can be used together with other tests to select patients in whom further study is necessary.

Principais Exames Complementares Solicitados para o Diagnóstico das Apendicites Agudas em Adultos em um Hospital do Sul de Santa Catarina / Main complementary exams requested for the diagnosis of acute appendicitis in adults in a hospital in southern Santa Catarina

Introdução: A apendicite aguda exige, na maioria das vezes, um procedimento cirúrgico urgente. Grande parte das pessoas acometidas pela doença apresenta clinicamente sinais e sintomas característicos. Essa doença possui diagnóstico iminentemente clínico, porém podem-se solicitar exames complementares para a elucidação diagnóstica em casos específicos. Quanto à escolha do tratamento, a apendicectomia ainda é a opção principal. Objetivo: Identificar os exames solicitados para o diagnóstico das apendicites operadas nas pessoas adultas no Hospital Nossa Senhora da Conceição, através do Sistema Único de Saúde (SUS), em Tubarão/SC, entre 15 de janeiro e 15 de julho de 2018. Métodos: Trata-se de um estudo epidemiológico observacional com delineamento transversal. Resultados: A média de idade foi de 34,78 anos, sendo a mínima, 18 anos e máxima, 88 anos. A raça mais frequente foi a branca (40 - 66,67%). O sexo predominante foi o masculino (35-58,33%). O local mais escolhido para primeiro atendimento médico foi o HNSC. Entre os pacientes em estudo, 37 obtiveram pontuações entre 7 e 10 na escala de Alvarado. A demora entre o início dos sintomas até a procura por auxílio médico chegou a mais de 7 dias. Foram solicitados, ao todo, 389 exames complementares nas pessoas com suspeita de apendicite, sendo os mais requisitados hemograma, parcial de urina, ultrassonografia, amilase e raio X. Conclusão: Predominaram homens, idade média de aproximadamente 35 anos, raça branca e moradores do município de Tubarão/SC.

Introduction: Acute appendicitis requires, in most cases, an urgent surgical procedure. Most people affected by the disease clinically present characteristic signs and symptoms. This disease has an imminently clinical diagnosis, but complementary tests may be requested for diagnostic elucidation in specific cases. As for the choice of treatment, appendectomy is still the primary choice. Objective: To identify the tests requested for the diagnosis of appendicitis operated on adults at the Hospital Nossa Senhora da Conceição (HNSC), through the Unified Health System (SUS), in Tubarão/SC, between January 15 and July 15, 2018. Methods: This is an observational epidemiological study with a cross-sectional design, and the statistical analysis used the PSPP 1.0.1 software. Results: The mean age was 34.78 years, with the minimum being 18 and the maximum being 88 years. The most frequent race was white (40 - 66.67%). The predominant gender was male (35-58.33%). The most chosen place for first medical attention was the HNSC. Among the patients under study, 37 scored between 7 and 10 on the Alvarado scale. The delay between the onset of symptoms and the search for medical help was more than seven days. The 389 complementary exams were requested for the people with suspected appendicitis, being the most requested hemogram, partial urine test, ultrasonography, amylase, and X-ray. Conclusion: There was a predominance of men, mean age of about 35 years, white, and residents of Tubarão. A total of 389 complementary exams were requested.

Apendicite aguda na infância: epidemiologia, quadro clínico e exames complementares / Acute appendixis in the infancy: epidemiology, clinical picture and complementary exams

Acute appendicitis is a common disease among children, with an incidence peak between 10-20 years of age and a higher prevalence in males. It often presents with periumbilical pain that migrates to the right iliac fossa, accompanied by symptoms. The diagnosis is clinical; however, some tests can be helpful, such as: blood count, PCR, partial urine, ultrasonography, X-ray, computed tomography and magnetic resonance imaging. The aim of this study was to verify the prevalence of appendicitis according to sex and age and the most prevalent clinical symptoms in the infancy. Retrospective study analyzing the medical records of patients who underwent appendectomy. Epidemiological characteristics, clinical aspects, physical examination and complementary exams of the patients were identified. In conclusion, acute appendicitis is suspected in a male, aged between 6-12 years, with abdominal pain, fever, nausea, vomiting, diarrhea, anorexia or positive Blumberg, aided by complementary tests, being ultrasonography and laboratory tests preferred

A apendicite aguda é doença comum entre as crianças, tendo pico de incidência entre os 10-20 anos e maior prevalência no sexo masculino. Frequentemente ela cursa com dor periumbilical que migra para a fossa ilíaca direita, acompanhada de sintomas. O diagnóstico é clínico; entretanto, alguns exames complementares podem ser de grande valia: hemograma, PCR, parcial de urina, ultrassonografia, raio-X simples, tomografia computadorizada e ressonância magnética. O objetivo desse estudo foi verificar a prevalência de apendicite de acordo com o sexo e idade e os sintomas clínicos mais prevalentes na infância. Estudo retrospectivo analisando prontuários de pacientes que realizaram apendicectomia. Foram identificadas as características epidemiológicas, quadro clínico, exame físico e exames complementares tes. Em conclusão, é suspeitada apendicite aguda em paciente masculino, entre 6-12 anos, com dor abdominal, febre, náuseas, vômitos, diarreia, anorexia ou Blumberg positivo, auxiliados por exames complementares, sendo a ultrassonografia e os exames laboratoriais os preferenciais.

Pileflebitis como complicación de apendicitis aguda en paciente gestante / Pylephlebitis as a Complication of Acute Appendicitis in a Pregnant Patient

Introducción: La pileflebitis, trombosis séptica del sistema portal por cuadros inflamatorios agudos abdominales, se presenta con manifestaciones clínicas variables en dependencia de la causa de origen y por rama portal afectado. El diagnóstico incluye función hepática normal o ligeramente alterada con leucocitosis, hemocultivos positivos, eco doppler o tomografía computarizada que corrobore la enfermedad. Objetivo: Describir la pileflebitis como una complicación inusual en una paciente embarazada con apendicitis aguda, desde su concepto, fisiopatología, presentación clínica, diagnóstico y medidas terapéuticas. Caso clínico: Paciente femenina de 18 años, gestante, que refirió dolor abdominal de gran intensidad, acompañado de vómito y deposiciones diarreicas y tinte ictérico. Por tales motivos fue trasladada al Hospital General Docente Ambato. Se diagnosticó sepsis de origen abdominal por apendicitis aguda perforada, peritonitis generalizada complicada con pileflebitis. Se realizó intervención quirúrgica y resolución del cuadro clínico. Conclusiones: La pileflebitis presenta una gran dificultad diagnóstica, por lo que herramientas como la ecografía doppler y la tomografía computarizada son de ayuda en estos casos. Los pilares del tratamiento incluyen control del foco séptico abdominal y tratar la pileflebitis(AU)

Introduction: Pylephlebitis, septic thrombosis of the portal system due to acute abdominal inflammatory conditions, it presents with variable clinical signs depending on the cause of origin and the affected portal branch. Diagnosis includes normal or mildly impaired liver function with leukocytosis, positive blood cultures, Doppler echocardiography, or computed tomography confirming the disease. Objective: To describe pylephlebitis as an unusual complication in a pregnant patient with acute appendicitis, referring to its concept, pathophysiology, clinical presentation, diagnosis and therapeutic measures. Clinical case report: This is the case of an 18-year-old female pregnant patient, who had severe abdominal pain, accompanied by vomiting, diarrhea and jaundiced stools. For such reasons, she was transferred to the Ambato General Teaching Hospital. Sepsis of abdominal origin was diagnosed due to acute perforated appendicitis, generalized peritonitis complicated with pylephlebitis. Surgical intervention was performed and the clinical condition was solved. Conclusions: Pylephlebitis represents a great diagnostic difficulty, hence tools such as Doppler ultrasound and computed tomography are helpful in these cases. The mainstays of treatment include control of the abdominal septic focus and treating pylephlebitis(AU)

Diverticulitis apendicular, como diagnóstico diferencial / Appendiceal diverticulitis as differential diagnosis

RESUMEN La diverticulitis apendicular (DA) es una patología poco frecuente, considerada clínicamente indistinguible de la apendicitis aguda, aunque podría presentar una sintomatología más leve. Este es el caso de un paciente masculino de 59 años, que concurre al Servicio de Urgencias presentando signos y síntomas sugestivos de una apendicitis aguda; una ecografía informa un asa tubular parcialmente compresible de 7,8 mm de diámetro y una fina banda de líquido laminar, compatible con proceso apendicular agudo. La apendicectomía se realizó de manera convencional evidenciándose un apéndice inflamado principalmente en su región distal. La histología reveló diverticulitis apendicular complicada con rotura. El paciente evolucionó favorablemente y se externó a las 24 horas. Existe una asociación de DA y neoplasia apendicular, por lo que se recomienda una colonoscopia y el seguimiento de este tipo de pacientes.

ABSTRACT Appendiceal diverticulitis (AD) is a rare condition considered clinically identical to acute appendicitis although it may present milder symptoms. We report the case of a 59-year-old male patient who visited the emergency department due to signs and symptoms suggestive of acute appendicitis. An abdominal ultrasound showed partially compressible tubular loop with a diameter of 7.8 mm and a thin band of laminar fluid, consistent with acute appendiceal process. During conventional appendectomy the appendix had signs of inflammation, mainly in the distal region. The histology revealed appendiceal diverticulitis complicated with rupture. The patient had favorable outcome and was discharged 24 hours later. As, there is a clear association between AD and appendiceal neoplasms, colonoscopy and patient monitoring is recommended.

Nueva propuesta de score para el diagnóstico de apendicitis aguda en adultos / A New Score Proposal for Diagnosing Acute Appendicitis in Adults

Introducción: La apendicitis aguda es una de las causas más comunes de abdomen agudo quirúrgico y dado que sigue siendo un reto diagnóstico, dispone de diversas escalas diagnósticas. Objetivo: Determinar la superioridad del nuevo score resultante frente al score de Alvarado en el diagnóstico de apendicitis aguda. Métodos: Se realizó un estudio de pruebas diagnósticas con el uso de la base de datos del Servicio de Cirugía del Hospital Regional Docente de Trujillo, entre febrero y diciembre del año 2015. Con los datos extraídos se elaboró un nuevo score diagnóstico que fue evaluado con el informe histopatológico y luego comparado con el score de Alvarado para evaluar su aplicación. Se calculó la sensibilidad, especificidad y los valores predictivos de ambos scores. Resultados: Se incluyeron en el estudio 312 pacientes, 177 fueron hombres (56,73 por ciento) y 135 mujeres (43,27 por ciento), con edad media de 31 años (±11,3). Con un total de 267 (85,58 por ciento) pacientes con apendicitis aguda confirmada por estudio histopatológico. El nuevo score clínico resultante de una regresión logística según la prueba de Wald, estuvo compuesto por 4 variables: sexo masculino, vómitos, automedicación previa y signo de Blumberg. Los resultados del área bajo la curva para el nuevo score clínico y el score de Alvarado fueron 0,711 y 0,707, respectivamente. Conclusiones: El nuevo score clínico es superior al score de Alvarado según el área bajo la curva, pero no en un valor significativo(AU)

Introduction: Acute appendicitis is one of the most common causes of acute surgical abdomen. Since it remains a diagnostic challenge, it has several diagnostic scales available. Objective: To determine the superiority of a new resulting score versus the Alvarado score in the diagnosis of acute appendicitis. Methods: A study of diagnostic tests was carried out using the database of the surgery service of the Regional Teaching Hospital of Trujillo, between February and December 2015. With the data collected, a new diagnostic score was elaborated and assessed with the histopathological report; and then, to assess its application, it was compared with the Alvarado score. Sensitivity, specificity and predictive values of both scores were calculated. Results: 312 patients were included in the study, 177 were male (56.73 percent) and 135 were female (43.27 percent), with a mean age of 31 years (±11.3). A total of 267 (85.58 percent) patients had acute appendicitis confirmed by histopathological study. The new clinical score resulting from a logistic regression according to the Wald test was made up of four variables: male sex, vomiting, previous self-medication and Blumberg's sign. The results of the area under curve for the new clinical score and the Alvarado score were 0.711 and 0.707, respectively. Conclusions: The new clinical score is better than the Alvarado score, according to the area under curve, but not by a significant value(AU)

Severity Markers of Acute Appendicitis: Diagnostic Test Study / Marcadores de severidad de la apendicitis aguda: estudio de prueba diagnóstica

Abstract Introduction: Acute appendicitis (AA) is one of the most frequent abdominal surgical pathologies globally, with appendectomy being the most performed emergency surgery. Aim: To determine potential markers of AA severity for diagnostic purposes and timely management, thus avoiding possible complications. Materials and methods: This research relies on a randomized sample of 239 patients diagnosed with AA at the Orinoquía Regional Hospital, Colombia. We analyzed blood count, C-reactive protein (CRP), and neutrophil/lymphocyte ratio (NLR) records and established their relationship with the AA surgical findings described by Guzmán-Valdivia. Results: In the emergency department, these reactants can provide an approximate diagnosis as markers of the AA severity, with CRP > 15 mg/dL (diagnostic accuracy of 76.15 %) and NLR > 85 % (diagnostic accuracy of 61.09 %) having the best initial operating performance. Regarding complications such as intestinal perforation, we found a statistical relationship; CRP > 15 mg/dL and NLR > 85 % were the markers with the highest predictive performance, with OR 14.46 and OR 2. 17, respectively, regarding Guzmán-Valdivia's findings. Conclusions: CRP and NLR > 85 % are the acute phase reactants with the best diagnostic characteristics to predict potential AA complications.

Resumen Introducción: la apendicitis aguda (AA) es una de las patologías quirúrgicas abdominales más frecuentes en el mundo, siendo la apendicectomía, la cirugía de emergencia más realizada a nivel mundial. Objetivo: determinar los posibles marcadores de severidad en la apendicitis aguda con fines diagnósticos y para el manejo oportuno de la apendicitis y, de esta manera, evitar posibles complicaciones. Metodología: esta investigación se basó de una muestra aleatorizada de un total de 239 pacientes con diagnóstico de apendicitis aguda en el Hospital Regional de Orinoquía, Colombia. Se analizaron registros de cuadro hemático, proteína C reactiva (PCR) e índice de neutrófilo/linfocito (INL), y se estableció la relación de los mismos con los hallazgos quirúrgicos de apendicitis aguda descritos por Guzmán-Valdivia. Resultados: en el servicio de urgencias, estos reactantes son capaces de realizar una aproximación en el diagnóstico y como marcadores de la severidad de la AA, siendo la PCR > 15 mg/dL (precisión diagnóstica 76,15 %) y el porcentaje de neutrófilos > 85 % (precisión diagnóstica 61,09 %) los de mejor rendimiento operativo inicial. En cuanto a las complicaciones, como la perforación intestinal, se encontró en relación estadística, que la PCR > 15 mg/dL y el porcentaje de neutrófilos > 85 % fueron los marcadores con mayor rendimiento predictivo, con OR 14,46 y OR 2,17, respectivamente. Lo anterior en relación con los hallazgos descritos por Guzmán-Valdivia. Conclusiones: la elevación de la PCR y del porcentaje de neutrófilos > 85 % son los reactantes de fase aguda que presentan mejores características diagnósticas y para predecir posibles complicaciones de la apendicitis aguda.

Case Report of a Metastatic Biliary Tract Neoplasm as an Unusual Cause of Appendicitis / Reporte de caso de neoplasia biliar metastásica como causa inusual de apendicitis

Abstract Introduction: We describe the case of a patient with appendiceal metastasis as the first manifestation of a cholangiocarcinoma. Main symptoms: Abdominal pain, jaundice, hyporexia, and choluria. Methods and results: We documented an appendiceal plastron histologically compatible with metastatic appendiceal adenocarcinoma, common hepatic duct stricture, and a suspected cholangiocarcinoma, later corroborated by endoscopic retrograde cholangiopancreatography. Conclusions: Metastatic appendiceal tumors are an infrequent and poorly studied manifestation, whereas those secondary to bile duct neoplasia have rarely been reported in the literature.

Resumen Introducción: se describe el caso de una paciente con una metástasis apendicular como primera manifestación encontrada de un colangiocarcinoma. Síntomas principales: expresado con dolor abdominal, ictericia, hiporexia y coluria. Métodos y resultados: se documentó un plastrón apendicular histológicamente compatible con adenocarcinoma apendicular metastásico, estrechez del conducto hepático común, con alta sospecha de colangiocarcinoma, corroborado luego con la realización de una colangiopancreatografía retrógrada endoscópica. Conclusiones: los tumores apendiculares metastásicos son una presentación infrecuente y poco estudiada, donde los secundarios a neoplasia de vía biliar se han reportados de forma muy escasa en la literatura.

Neoplasias apendiculares incidentales / Incidental appendicular neoplasms

Las neoplasias apendiculares se presentan hasta en el 50 % de los casos como un episodio de apendicitis aguda. Existen características demográficas, clínicas y radiológicas que aumentan las posibilidades de un tumor apendicular subyacente, sin embargo, en la mayoría de los casos, son los hallazgos intraoperatorios los que alertan al cirujano. A pesar de que el tipo histológico determina la radicalidad del manejo quirúrgico de estos pacientes, algunas características macroscópicas pueden orientar a las patologías específicas y a una conducta adecuada. En general, los objetivos del manejo quirúrgico inicial se cumplen con una resección limitada al apéndice cecal, asociada a la citología de mucina y biopsia de los implantes peritoneales si están presentes, reservando las resecciones extendidas, como hemicolectomía derecha oncológica, para los pacientes con compromiso extenso de la base o del mesenterio apendicular ante la sospecha de neoplasias neuroendocrinas o adenocarcinoma del apéndice cecal.

Appendicular neoplasms present in up to 50% of cases as an episode of acute appendicitis. There are demographic, clinical and radiological characteristics that increase the chances of an underlying appendicular tumor; however, in most cases are the intraoperative findings that alert the surgeon. Although the histological type determines the radical nature of the surgical management of these patients, some macroscopic characteristics can guide specific pathologies and appropriate behavior. In general, the objectives of initial surgical management are met with a limited resection of the cecal appendix, associated with mucin cytology and biopsy of peritoneal implants if present, reserving extended resections such as oncological right hemicolectomy for patients with extensive compromise of the base or appendicular mesentery when neuroendocrine neoplasms or adenocarcinoma of the cecal appendix are suspected.

Laparoscopic appendicectomy without the use of disposable materials - a low-cost alternative - 1, 552 cases operated in 20 years / Apendicectomia laparoscópica sem uso de materiais descartáveis - uma alternativa de baixo custo - 1. 552 casos operados em 20 anos

ABSTRACT Introduction: Laparoscopic appendectomy does not have a single protocol on its technical systematization, access routes, and use of energy and staplers. The cost of disposable materials can prevent its widespread use. Alternatives to decrease cost can help disseminate the laparoscopic access to appendectomy. Objective: to introduce a low-cost laparoscopic appendectomy method with good aesthetic results through the location of incisions; to show its viability through its application in 1,552 cases of laparoscopic appendectomy operated between 2000 and 2019 with three portals and very low-cost regarding materials used. Methods: we applied three punctures - an umbilical one for the camera (5 or 10mm in diameter), a 10mm puncture in the right iliac fossa, and one 5mm puncture in the left iliac fossa. The materials used were permanent use trocars, grasping forceps, hook, scissors, and needle holder, without the need for any disposable device. Results: 1.552 patients were operated between 2000 and 2019, 56.2% being female, mean age 32.66 years (9-93), average hospital stay of 1.74 days (1-10), and median of 1.2 days. Conclusion: the technique we describe uses three metallic trocars and four permanent instruments, in addition to a single cotton suture. It is, therefore, a very low-cost laparoscopic procedure. Its application has shown good results and low morbidity, which may become the preferred indication for laparoscopic surgery in the treatment of acute appendicitis.

RESUMO Introdução: a apendicectomia videolaparoscópica não tem protocolo único sobre sistematização técnica, vias de acesso, uso de energia e grampeadores. O custo de materiais descartáveis pode inviabilizar o emprego mais generalizado. Alternativas para diminuir o custo podem ajudar a disseminar o acesso laparoscópico para a realização de apendicectomia. Objetivo: introduzir um método para realizar a apendicectomia videolaparoscópica de baixo custo e visando bom resultado estético por meio da localização das incisões; mostrar a viabilidade por meio de aplicação em 1.552 casos de apendicectomia videolaparoscópica operados entre 2000 e 2019 com três portais, de muito baixo custo em insumos utilizados. Métodos: três punções - uma punção umbilical para introdução da câmera (de 5 ou 10mm de diâmetro), uma punção de 10mm em fossa ilíaca direita e uma punção em fossa ilíaca esquerda de 5mm. Os materiais utilizados - trocartes, pinças de apreensão, gancho, tesoura e porta-agulhas são de uso permanente, sem necessidade de qualquer material descartável. Resultados: foram operados 1.552 pacientes entre 2000 e 2019, sendo 56,25% do sexo feminino, média de idade de 32,66 anos (9 a 93 anos), tempo médio de internação de 1,74 dias (1 a 10 dias) e mediana de 1,2 dias. Conclusão: a técnica que descrevemos utiliza três trocartes metálicos e quatro instrumentos permanentes, além de um único fio de algodão. Trata-se, portanto, de procedimento laparoscópico de muito baixo custo. A aplicação demonstrou bons resultados e baixa morbidade, podendo tornar-se rotina a indicação preferencial da vídeocirurgia no tratamento da apendicite aguda.

Abdominal pain in the female patient: A case of concurrent acute appendicitis and infected ovarian cyst

Background: Abdominal pain is a common presentation in women of child bearing age. It has a broad diagnosis that includes disorders of the gastrointestinal, gynaecological, vascular, urogenital, and pulmonary systems. It may be caused by infections, inflammatory, anatomic or neoplastic processes. Its management varies by aetiology, and accurate diagnosis is key to avoiding inappropriate treatment. In some rare instances, acute appendicitis has been shown to occur simultaneously with a variety of gynaecologic diseases, which can add to the diagnostic dilemma. Method: We report a case of concurrent acute appendicitis and infected ovarian cyst in a 49 year old P6+4A6 who presented with recurrent abdominal pain for 4 years duration. Result: She had oophorectomy and appendicectomy. She did well post operatively and was discharged to outpatient department after stitches removal. Conclusion: Abdominal pain, being from various aetiology in women of child bearing age, detail history, thorough physical examination, and necessary imaging investigations need to be done to avoid misdiagnosis and inappropriate treatment.

Corpus luteum rupture mimicking acute appendicitis

Acute abdomen is a common presentation in women in the reproductive age. It may be caused by diverse conditions. The case below presented with classical signs and symptoms of appendicitis. Haemoperitoneum seen at laparotomy suggested a diagnosis of ectopic pregnancy .The diagnosis of ruptured corpus luteum cyst (RCLC) was made only after histology. The symptoms, signs and diagnosis of RCLC are discussed. The case highlights the need for circumspection in the diagnosis of the cause of acute abdomen. The current trend favours conservative management of RCLC thus the need for a high index of suspicion is emphasized to avoid unnecessary surgery.