European Journal of Molecular & Clinical Medicine

Acute appendicitis is a commonly encountered surgical emergency it has a lifetime prevalence of 1 in 7. With an incidence of 1.5-1.9 per 1000 in male and female population, and 1.4 times more common in men. The diagnosis is based on a thorough clinical history and examination. It is well supported with efficient laboratory investigations like elevated leucocyte count and ultrasound of the abdomen. Acute appendicitis is a common problem yet a difficult diagnosis at times specially in young and elderly females. Females of reproductive group are more prone for other genitourinary problems that may mimic acute appendicitis. Any delay in performing an appendicectomy to improve its diagnostic accuracy, can increase the risk of complications like appendicular lump, perforation and sepsis, which will in turn increase the morbidity and mortality

IMPORTANCE: Valentino's syndrome is caused by a peptic ulcer perforation in which stomach contents leak and accumulates in the iliac fossa on right side, causing focal inflammation and discomfort in the right lower quadrant mimicking appendicitis. It is a rare case with only a few cases recorded in the review of literature.
OBJECTIVE: This study aims to discuss an unusual clinical presentation of a rare case of Valentino syndrome and about how the initial diagnosis of acute appendicitis was diagnosed to a case of perforated peptic ulcer with the help of CECT Abdopelvis and USG.
CASE PRESENTATION:  A 25/male who presented with pain in the right inferior quadrant for 3 days associated with  vomiting and fever with positive Mc Burney and Rovsing sign on examination was diagnosed clinically as acute appendicitis. USG showed duodenal perforation with perforation site sealed off by omentum. On CECT Abdomen, pneumoperitoneum was noted but the site of the perforation was not found. Intraoperatively, first part of duodenum showed a sealed off perforation without any perforation at other site. Patient was diagnosed as a case of Valentino syndrome.
CONCLUSION: Clinicians must be aware that though unusual, perforated peptic ulcer can present as a differential diagnosis for right iliac fossa pain. For a diagnosis, a strong index of suspicion and a proper radiographic assessment is required. If a perforated peptic ulcer is not treated promptly, it can progress to sepsis, multiorgan failure, and death.

Aim: To study the diagnostic role of rise in bilirubin in Acute appendicitis.
Materials and method: Prospective analytical study of Pre-operative Role of Rise in Bilirubin in acute appendicitis was carried out in December 2019 – April 2021. All cases coming with uncomplicated acute appendicitis admitted during study period in Sharda Hospital, Gr. Noida, UP. were included in study. Patients withPre-operative diagnosed case of acute appendicitis with age above 18 years were included. The patients with Complicated appendicitis, Negative proved specimen on Histopathalogy Examination, Patients suffering from Positive HBs Ag, Previous history of Jaundice, Chronic Alcoholism (daily intake of >40 ml for male &>20 ml for female),Patients suffering from Hemolytic Disease, Congenital biliary disease, Hepato-biliary malignancy, Recent history of liver trauma, Cholelithiasis, Females with history of oral contraceptive pill, Patients with history of Statins, Pregnancy were excluded from the study. A detailed history, complete physical examination and routine & appropriate investigations were done for all patients.
Results: The mean age of the study population was 29.46±9.81 (18-70) years with majority of the study population belonging to 18-30 years (62.7%) followed by 31-40 years (22.7%) and above 39 years (14.5%). The study population consisted of 78 (70.9%) males and 32 (29.1%) females. The mean Total Sr. Bilirubin (mg/dL), Direct (mg/dL) and Indirect (mg/dL) among study population was 0.98±0.37 (0.29-2.11), 0.77±0.33 (0.28-1.72) and 0.20±0.21 (0.00-1.73). The mean Alvarado Score of the study population was 7.40±0.59 (7-9). The mean Total Sr. Bilirubin (mg/dL) was significantly more among subjects with Alvarado score≥ 7 compared to subjects with Alvarado score7. Frequency Percent Paracaecal 18 16.4% Pelvic 1 0.9% Retrocaecal 89 80.9% Subcaecal 2 1.8% Total 110 100.0% The Pre-operative findings showed that appendicitis was Paracaecal, among 18 (16.4%), Pelvic, among 1 (0.9%), Retrocaecal, among 89 (80.9%) and Subcaecal, among 2 (1.8%) subjects. There was no significant difference in mean TLC (/mm3) between subjects with Abnormal and Normal Bilirubin level. The mean C-Reactive Protein (mg/dL) was significantly more among subjects with Abnormal Bilirubin level compared to Normal Bilirubin level.

Background: Appendicitis is anticipated to affect about 6% of the population at some point in their lives. The reduced prevalence of acute appendicitis in Asian and African nations is likely due to the dietary patterns of these populations. Objectives: To compare the diagnosis of acute appendicitis by Alvarado score to that by histopathological examination as well as to determine whether there is any correlation between dietary intake pattern and the occurrence of acute appendicitis. Methodology: It was a prospective cohort study involving 148 participants attending surgery OPD between 08 months from June 2021 to January 2022. Detailed history and clinical examination was done followed by admission and laboratory investigations. Confirmation of diagnosis was done based on modified Alvarado scoring system and ultrasonography. Results: After analysis of 148 study participants, it was found that 88% of them belong to age group of >18 upto 40 years and 63% of them were males. No significant association was found between diet and appendicitis.Conclusion: Both Modified Alvarado Scoring System (MASS) and histopathological examination was found to be diagnostic for appendicitis.

Aim: To study the efficacy of laparoscopic appendectomy as well as conversion rate of laparoscopic appendectomy to open appendectomy.

Background: Acute appendicitis is the commonest surgical emergency worldwide and an acceptable negative appendectomy rate is 15-20%.The diagnosis of acute appendicitis is based on signs and symptoms whose interpretation is sometimes subjective (anorexia) and varied (pain perception, referral) and thus the diagnosis of appendicitis has always been a challenge to emergency surgeons. The difficulty in availability of the investigations and the costs incurred are a deterrent factor for most of the emergency units across the world and hence a need for a comprehensive scoring system for the diagnosis of acute appendicitis is the matter of the relevance today. Aim & Objective: To study the diagnostic accuracy of RIPASA score with comparison to ALVARADO score in the diagnosis of acute appendicitis.
Materials and Methods: The study site is Government Medical Colleg, Suryapet Telangana, India.
Results: The Alvarado score, developed in 1986, is based on the points as enumerated by the acronym MANTRELL (each alphabet denoting a parameter assessed) and has been a popular scoring system for use worldwide. The reported literature suggests a sensitivity, specificity in the range of 53 to 88% and 75 to 80% respectively. The RIPASA (Raja Isteri Pengiran Anak Saleha Appendicitis) score was introduced in the year 2009-2010. The reported literature suggests sensitivity of 97.5%, specificity of 81.8%, PPV of 86.5%, NPV of 96.4% and a diagnostic accuracy of 91.8%. In an emergency setting, the on duty Medical Officer can make a quick decision upon seeing the patients with RIF pain by referring those with a RIPASA score ≥ 7.5 to the on-call surgical team for admission, while patients with a RIPASA score < 7.0 can either be observed in the ward or sending home with advice to patient party for observation. Thus RIPASA score is currently a much better diagnostic scoring system for acute appendicitis compared to the Alvarado score, with the former achieving significantly higher sensitivity, NPV and diagnostic accuracy, particularly in Indian population setting.
Conclusion: Further studies need to be done with larger patient population to validate the results obtained in this study. The importance of the RIPASA scores in context with other contemporary scores (e.g. Modified Alvarado with cut off at 6) needs to be evaluated in future

Introduction: Acute appendicitis is one of the most common acute conditions that needs an emergency surgical intervention. It is widely acceptable that delay in diagnosis and treatment significantly contribute to increased incidences of perforated appendicitis, which eventually results in increased chances of patient morbidity. It has accepted generally that an appendectomy should be performed within a few hours of diagnosis and that a delay in the operation may lead to a greater incidence in the morbidity.
Methodology: In this study, we took an effort to assess whether appendectomy for acute appendicitis can be safely delayed for 72 hours after the initial diagnosis in our hospital. We included patients who underwent appendectomies after a preoperative diagnosis of acute appendicitis that was confirmed after pathological examination. There are some patients who were younger than 15 years, patients who underwent negative appendectomies, incidental appendectomies, or interval appendectomies were excluded from the study. Patients who were included in the study were divided into 2 groups mainly. The early group comprised patients who underwent appendectomies within 72 hours after presentation to the emergency department. The late group comprised patients who underwent appendectomies 72 hours after presentation. There were several reasons for the delay in the operation: the time between admission to the emergency department and surgical consultation, the lack of operating room availability, a delay in the diagnosis owing to an atypical presentation, and the surgeon’s decision to delay the surgical procedure. Oral intake was stopped for patients in both groups for the preparation of surgical intervention. The t - test and Fisher exact test were used to analyse the statistical difference between these 2 groups. We calculated a sample size of 152 patients in each group to detect an increase of 10% in the rate of advanced appendicitis, with a power of 80%.4 A P value of <0.05 was considered statistically significant.
Results: Three hundred and eleven patients were included in the study. Out of which were 166 men and 145 women. The average age was calculated to be 28 years (age range, 15-40 years). There were 233 patients in the early group and 76 patients in the late group. The mean ± SD time between presenting to the emergency department and surgery was 6.7±2.7 hours for the early group and 16.7±3.6 hours for the late group. Both groups were comparable with respect to age, sex, white blood cell count, and temperature. There were no statistically significant differences between the 2 groups in the length of stay (P=0.17), average operative time (P=.93 for laparoscopic surgery; P=0.14 for open surgery), rate of advanced appendicitis (P=0.56), and complication rate (P=.74) (In comparing the time of presentation to the emergency department and the time of operation, 54% of patients were admitted to the emergency department during the day hours (7 AM–7 PM) vs 46% during the evening and night hours (7 PM–7 AM). This percentage was reversed slightly when observing the time of operation: 57% during the evening and night hours vs 43% during the day hours.
Conclusion: A successful approach in the treatment of acute appendicitis includes the early administration of intravenous antibiotics and fluid hydration followed by the appendectomy procedure during the day hours does not increase the rate of complications and it does not significantly increase the length of stay or rate of advanced appendicitis. In addition, this practice pattern decreases the need for operating during the late-night hours or the interruption of the regular operating room schedule. Finally, it aids in focusing resources and operating room availability to life-threatening emergencies.

Background: Acute appendicitisis a very common cause of acute abdomen requiring surgical intervention with an incidence of about 100 per 10000.
Material and methods: A retrospective analysis of medical data based records of 109 consecutive patients who were undergone surgery in department of general surgery in LN Medical College, Bhopal for the diagnosis of acute appendicitis from June 2019 to July 2021 was done. Data was collected from patient on the basis of age, sex , clinical diagnosis pre operative finding. Data was analyzed by using Microsoft excel and statistical package of social sciences (SPSS).
Results: In the present study 109 patients were included in which 60.55% were males and 39.44% were females. Maximum patients were in the age group of 21-30yrs (55.04%) followed by 31-40yrs(30.27%) and 41-50 yrs(14.67%). Migration of pain, RIF Tenderness, leucocytosis was found in 100% patients . Anorexia was found in 80.73% patients, nausea, rebound pain, elevated temperature was found in 75.22% patients respectively. Inflamed appendix was found in 100% patients, appendicular abscess was found in 17.43% patients, Appendicular Perforation was found in 20.18% patients, Faecolith with Inflamed Appendix was found in 15.59% patients. Open Appendicectomy was done in 60.55% patients  and Laparoscopic Appendicectomy was done in 39.44% patients. Maximum patients ie 44.95% were stayed for 4 days in the hospital.
Conclusion: The present study shows that acute appendicitis in India is a disease of young males. On further sub-classification of acute appendicitis, uncomplicated acute appendicitis seems to be the most common. Delayed presentation is associated with greater morbidity.

Background: Even though appendicectomy is the most regularly performed emergency surgery, its diagnosis remains uncertain, with a high probability of negative investigations. The study's goal was to investigate the relevance of CRP measurement accuracy in the diagnosis of acute appendicitis and to reduce morbidity by avoiding negative exploration.
Materials and Methods: The present investigation included 30 patients who were clinically diagnosed by surgeons as having acute appendicitis and were sent for an emergency appendectomy at the General Surgery Department, JSS Hospital Mysuru, between the 1st of December 2020 and the 1st of May 2021. Preoperative blood was sent for CRP estimation; postoperative, all specimens were sent for histopathological evaluation; CRP values were correlated with HPE reports to evaluate their function in the diagnosis of acute appendicitis.
Results: In the current study, CRP had the highest sensitivity and specificity of 90% and 80%, respectively, with a positive predictive value of 90%. As a result, it was demonstrated that CRP levels can be used to rule out negative appendicitis, allowing surgery to be postponed in these patients and lowering the rate of negative appendicectomies.
Conclusion: We continue to highlight the importance of a professional surgeon's history and clinical examination in detecting acute appendicitis. CRP, on the other hand, significantly reduces the rate of negative appendicectomy and, as such, should always be included in the diagnostic workup of acute appendicitis

Aim: The aim of this study to determine the value of pre-operative hyperbilirubinemia as a predictor of complicated appendicitis.
Material and methods: The study was a prospective observational study conducted in the Department of General Surgery……, India for the period of 1 year. Total 60 patients who were diagnosed to have appendicitis and admitted in surgery department and who underwent appendicectomy were included in the study. Clinical examination, blood routine examination, Alvarado score, ultrasound abdomen, histopathology examination, pre and post-operative values of total bilirubin, direct bilirubin and indirect bilirubin were studied.
Results: In our study 35 (58.33%) were males and 25 (41.67%) were females. Out of the 60 cases 26 were complicated. 37 cases had elevated bilirubin preoperatively in which 21 cases were having complications like gangrene, suppuration and perforation. Out of the 37 cases that had elevated bilirubin pre-operatively 19 (51.35%), the bilirubin level came down to normal limits after 72 hours of appendicectomy. On histopathology, 34 were acute appendicitis, 8 were perforated appendicitis, 6 were gangrenous appendicitis, 12 were suppurative appendicitis. From the study of sensitivity and specificity of pre-operative total bilirubin values in predicting perforated appendicitis, it was found that preoperative total bilirubin value of 1.59 mg/dl had the best sensitivity and specificity. Taking preoperative total bilirubin value 1.59 mg/dl as cut off in predicting perforated appendicitis the sensitivity was 68.8, specificity was 95.1 with an accuracy of 90.2.
Conclusion: Patients with appendicitis with elevated bilirubin levels have more chance for complications like perforation, gangrene and suppuration.

Background:Appendicitis occurs most commonly between the ages of 10 and 20 years and it has a male-to-female ratio of 1.4:1. The present study assessed validation of RIPASA score in diagnosis of suspected cases of acute appendicitis. Materials & Methods:86 patients with right iliac fossa pain and suspected to have acute
appendicitis of both genders were assessed. All were assessed using the RIPASA scoring system on the basis of clinical assessment and hospital protocol, histopathological correlation done with a score. A score of 7.5 was considered a cut-off value for high probability of acute appendicitis. Results: Out of 86 patients, males were 52 and females were 34. RIPASA score <5 was seen in 15, 5-7 in 20, 7.5- 11.5 in 38 and >12 in 13. Emergency appendectomy was performed on 62, positive HPE reports for appendectomy was seen in 54, negative HPE for appendectomy in 8, perforated appendix in 4 and wound sepsis in 7 cases. Conclusion: RIPASA score is a better, easy, safe, and non-invasive diagnostic method for diagnosis of acute appendicitis.

Background: Laparoscopic appendectomy (LA) is now the standard of management
for cases of acute appendicitis. LA has the benefits of minimal access surgery.
There are many methods for securing the base of the appendix, some of which are
expensive others are not available or technically demanding. This study is aimed to
compare between ligation and clipping techniques regarding fesibility , safety ,
efficacy, operative time , postoperative outcome and complications. Patients and
methods: A randomized prospective clinical trial study included 90 patients with
acute appendicitis. The patients were randomly distributed into 2 main groups
(A&B): 54 patients we secured the base of the appendix by ligation methods (group
A) and in 36 patients by clip application (group B). All patients were subjected to
classic history taking and clinical examination. Radiological investigation:
ultrasonography was routinely done for all patients. CT with contrast was requested
when indicated in suspicion of complications. Surgical ligation or clipping were
performed. Results: There is statistically non-significant difference between
patients underwent different surgical techniques as regarding application of
peritoneal drainor conversion to open. Two patients within ligation group (A) had
been converted to open due to presence of friable base in one case and intraoperative
bleeding in other case while three patients within clipping group (B) had
been converted to open due to intestinal injury, friable base and intra-operative
bleeding .Two cases in clipping group (B) had been converted to ligation techniques
due to very wide base which can't be secured by clip application. Conclusion:
Ligation and clipping techniques were effective, safe ,feasible and same in
complications rate. Clip application is related to less operative time , easier
application and simpler for trainee than ligation techniques which require
more experiences.

Background: Acute appendicitis (AA) is the most common surgical disease with a lifetime risk
of 7–8%.Traditionally, appendectomy has been the treatment of choice for acute appendicitis.
Mortality rate after appendectomy is very low and may range from 0.07 to 0.7% rising to 0.5 to
2.4% in patients without and with perforation. Over 250,000 appendectomies are performed each
year in the USA alone.It was observed during the outbreaks of influenza and Middle East
Respiratory Syndrome (MERS) in 2012 , that referrals for non-respiratory causes decreased
significantly as the epidemics progressed. An outbreak of respiratory disease should not by itself
affect the incidence and presentation of acute appendicitis. Nevertheless, we have noticed in our
institution that as the COVID-19 pandemic spread in our community there was a significant
decrease in the number of cases of acute appendicitis presenting to the ED of our institution and
an increase in the number of admitted patients of AA requiring surgery.
Objectives: To compare the incidence and presentation of aute appendicitis before and during
the COVID-19 lockdown period.Also, to compare thepercentage of patients requiring operative
management, intraoperative findings and postoperative complications before and during the
COVID-19 pandemic for cases of acute appendicitis.
Methodology:This prospective observational cohort study was undertaken at Government
Medical College Baramulla which is a 300 bedded teaching hospital catering as a referral
institute for a catchment population of roughly 1.2 million. All consecutive patients of clinically
or radiologically diagnosed AA admitted between 25th March and 25th July were included in
this study (corresponding to complete lockdown in our country). This was designated as group
A. Data was also collected from hospital records of all acute appendicitis patients admitted in the
corresponding months of 2019 i.e from 25th March 2019 to 25th July 2019 and analysed for
comparison and designated as group B

Background: Acute appendicitis, a quotidian diagnosis for acute abdomen, the diagnosis of which remains arduous.
Methods: A 70 consecutive patients suspected of acute appendicitis who were admitted in department of surgery, Rajah Muthiah Medical College and Hospital. They were prospectively assessed by the modified Alvarado scoring (MAS) to diagnose acute appendicitis. The MAS was compared with USG and histopathological findings.
Results: (true positive) patients who had MAS 7 or more had appendicitis on histopathology while no patients (false positive) had a normal appendix; (false negative) patients with MAS less than 7 had appendicitis and (true negative)had a normal appendix removed.
Conclusion: The MAS should be combined with USG for the diagnosis of acute appendicitis, although clinical evaluation remains the cornerstone of diagnosis of acute appendicitis.

Background:Appendicitis is most frequently seen in patients in their second and third decades of lifebut it is quite rare in the young age, probably because the configuration of the appendix at this age makes obstruction of the lumen unlikely. There is a rough parallelism between the amounts of lymphoid tissue in the appendix and the incidence of acute appendicitis. The aim of the present study was toevaluate intra-operative difficulties and operative time in laparoscopic method versus open Appendectomy. Toassess post-operative bowel movement recovery, start of oral intake, resuming physical activity, length of hospital stay and analgesia use frequency in adults with complicated appendicitis.Patients and methods:A prospective cohort study was conducted on 26 adult patients with complicated acute appendicitis. Patients were divided into 13 patients for laparoscopic appendectomy (LA) and 13 patients for open appendectomy (CA) at Emergency unit of General surgery department ofZagazig University Hospitals. Before treatment, all patients were evaluated clinically by using "the modified Alvarado score", laboratory investigations and radiological investigations. Results: We found that the mean operating time in laparoscopic appendectomy was shorter than that in the open approach. The overall post-operative complications were lesser in laparoscopic group. The incidence of wound infection was in open group (15.4%). This finding supports the current surgical dogma that early treatment for appendicitis by laparoscopy is the best practice, to prevent further inflammation of the pelvis by removing the source of infection. Conclusion: LA constitutes a safe and feasible procedure for the treatment of CA. In the case of CA, endobags and endostapler should be used or the appendiceal stump should be inverted after applying Roeder knots.

Background: Acute Appendicitis is the most common non obstetric surgical emergency during pregnancy that can occur throughout pregnancy but difficulty in diagnosis and delayed treatment can be associated with adverse maternal and pregnancy outcome.
Patients and Method: A prospective, observational study conducted in the Department of General Surgery at Baquba Teaching Hospital – Diyala – Iraq, from April 2016 to April 2020. Seventeen pregnant women, with acute appendicitis, were included.The patients' age ranged from 19 - 39 years with a mean age of 25 years. The patients' history, operative findings, postoperative outcome and histopathology results were recorded and analyzed.
Result: Four patients were in the first trimester, 8 patients were in the second trimester while 5 patients were in the third trimester. Abdominal pain was the main symptoms in all patients followed by poor appetite and nausea, while the main physical signs were tenderness and rebound tenderness in right lower quadrant of the abdomen. The appendix was grossly inflamed in 16 patients and was normal in one patient as proved by histopathology. During the follow up period, 3 patients had surgical site infection (SSI) and treated conservatively, 2 patients had preterm contractions and treated by tocolytic drugs, while fetal loss occurred in one patient.
Conclusion: Acute appendicitis is a common surgical emergency during pregnancy but high degree of suspicion and skills are required for early diagnosis with subsequent proper management to avoid possible complications both to the fetus and the mother