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A 68-year-old man was admitted with hematochezia. Emergency computed tomography showed multiple diverticula throughout the colon. Initial colonoscopy on day 2 showed no active bleeding, but massive hematochezia on day 3 led to the performance of an emergency endoscopy. Substantial bleeding in the ileocecal area obscured the visual field, making it challenging to view the area around the bleeding site. Two endoscopic band ligations (EBLs) were applied at the suspected bleeding sites. Hemostasis was achieved without active bleeding after EBL. However, the patient developed lower right abdominal pain and fever (39.4°C) on day 6. Urgent computed tomography revealed appendiceal inflammation, necessitating emergency open ileocecal resection for acute appendicitis. Pathological examination confirmed acute phlegmonous appendicitis, with EBLs noted at the appendiceal orifice and on the anal side. This case illustrates the efficacy of EBL in managing colonic diverticular bleeding. However, it also highlights the risk of appendicitis due to EBL in cases of ileocecal hemorrhage exacerbated by poor visibility due to substantial bleeding. Endoscopists need to consider this rare but important complication when performing EBL in similar situations.

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Meckel's diverticulum (MD) is a common congenital defect of the small intestinal tract resulting from incomplete obliteration of the vitellointestinal duct. It presents with unexplained gastrointestinal bleeding, bowel obstruction, and inflammation. In rare instances, the presentation is with perforation similar to acute appendicitis with perforation. The symptoms, clinical exam, and radiological findings of our patient, a 38-year-old male, were consistent with perforated acute appendicitis; he was found to have a perforated Meckel's diverticulum intraoperatively.

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Appendicitis is predominantly observed in teens and young adults. While typical causes include fecalith-induced luminal obstructions, in older adults less common etiologies such as tumors should be considered. This report highlights a rare case of appendicitis secondary to cecal adenocarcinoma in a high-risk patient with a history of obesity and type 2 diabetes mellitus. This case underscores the necessity of considering malignancy as a differential diagnosis in older adults presenting with appendicitis-like symptoms.

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Acute appendicitis that is not diagnosed and treated promptly typically results in serious complications that raise the risk of necrotizing fasciitis, particularly in elderly patients. We present a case of a 77-year-old male, who presented to the emergency department with a clinical manifestation of Fournier's gangrene caused by acute perforated appendicitis. The patient had no symptoms or signs of an acute abdomen, and within three days he developed significant unilateral scrotal swelling and skin changes. Our case demonstrates the need to treat Fournier's gangrene as a consequence of an intra-abdominal infectious disease, particularly in elderly comorbid patients with atypical symptoms of acute appendicitis, and highlights the importance of early surgical intervention.

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We present a case of multiple abdominal pathologies occurring simultaneously, which emphasizes the importance of keeping a broad differential and evaluating each diagnosis. A 33-year-old female presented with abdominal pain, nausea, and vomiting. Her workup included computerized tomography which demonstrated acute appendicitis with concern for a closed-loop bowel obstruction. She was offered diagnostic laparoscopy with anticipation of laparoscopic appendectomy and further evaluation for the source of the bowel obstruction. At the time of surgery, a Meckel's diverticulum with acute diverticulitis was identified, in addition to an inflamed appendix. A small band near the base of the Meckel's diverticulum was found and divided. The appendix was treated with a laparoscopic appendectomy and the Meckel's diverticulum was resected. She did well in recovery and continued to do well at her follow-up appointment. This case emphasized the importance of a thorough evaluation of a patient's differential diagnosis, as it is possible for multiple pathologies to occur simultaneously.

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Acute appendicitis is an ordinary surgical emergency, typically attributed to luminal obstruction by fecaliths or lymphoid hyperplasia. However, ingested foreign bodies as an etiology are rare but increasingly recognized, particularly in pediatric patients. We present the case of a 9-year-old male patient who presented to the emergency department with symptoms consistent with acute appendicitis. Further investigation revealed the presence of a bone fragment within the appendix, leading to acute inflammation. Foreign body ingestion should be considered in pediatric patients with acute appendicitis. This case report underscores the importance of comprehensive clinical evaluation and appropriate diagnostic imaging modalities in guiding optimal treatment strategies.

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BACKGROUND: The diagnosis and management of fever of unknown origin pose significant challenges in the field of infectious diseases, as it is influenced by various factors. Infectious diseases have long been recognized as the primary etiology of fever of unknown origin. However, not all infectious diseases can definitively identify the causative pathogen and infection sites. CASE PRESENTATION: we present a case report of an individual with fever, nausea, and anorexia but did not report any abdominal pain. Physical examination revealed no signs of abdominal tenderness. Repeated imaging studies including enhanced CT and color US of the appendix, only one color US suggested the possibility of appendicitis. Despite effective anti-infective treatment, the patient continued to experience low-grade fever, leading to the decision for laparoscopic exploration and subsequent appendectomy. Pathological findings confirmed the presence of appendicitis. After the surgical procedure, the patient's temperature and infectious markers returned to within normal range, ultimately leading to a diagnosis of appendicitis. CONCLUSIONS: The atypical symptoms and signs, along with the negative imaging results, contribute to the under diagnosis of appendicitis and the progression of fever of unknown origin, thereby exacerbating the physical, mental, and economic burden on patients. Consequently, there are valuable insights to be gained regarding the management of both appendicitis and fever of unknown origin.

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The prediction of the coexistence of acute appendicitis and renal colic can be challenging, especially when the patient's symptoms point toward one diagnosis. In this case report, we describe a patient who presented to the emergency department with severe lower abdominal pain that was thought to be solely due to acute appendicitis. Further evaluation, however, revealed the simultaneous coexistence of a right ureteral stone, causing severe hydroureteronephrosis. The patient underwent prompt surgical management, including laparoscopic appendectomy, ureteroscopy, and double-J stent insertion, and had an uneventful postoperative recovery.

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Superior mesenteric venous (SMV) thrombosis is a rare complication of severe appendicitis. Early recognition is due to improved imaging modalities, which ultimately lead to more prompt intervention. Despite being an uncommon phenomenon, SMV thrombosis can have complications stemming from venous hypertension, such as gastric and esophageal varices, bowel ischemia, sepsis, and death. As this is a rare phenomenon, specific treatment guidelines and algorithms are lacking in the current literature. This case report describes a 23-year-old male patient whose recovery from a laparoscopic appendectomy was complicated with both an SMV and portal vein thrombosis.

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Background: COVID-19 has further burdened the Brazilian healthcare system, especially emergencies. Patients may have delayed seeking care for surgical abdominal pain. Delays in the approach may have impacted clinical evolution and outcomes. This study evaluated appendectomies and their complications performed by the public system during one-year follow-up of COVID-19 in a hospital in southern Brazil. Materials and methods: In this hospital-based cross-sectional study, we included adult patients who underwent appendectomy from March 2019 to April 2021 (n = 162). Patients were divided into pre-pandemic (n = 78) and pandemic (n = 84) groups based on the surgery date. The analyzed variables included hospitalization duration, intensive care unit (ICU) admission, surgical approach, histopathological findings, COVID-19 testing, patient outcomes, and 30-day survival rate. Results: The cohorts exhibited similar epidemiology, with the sex ratio and average age being maintained. No statistical difference was found in the 30-day survival rate and clinical outcomes. Of the four patients admitted to the ICU, three belonged to the pandemic cohort and tested negative for COVID-19. Only 47.6 % of the patients in the pandemic cohort underwent COVID-19 polymerase chain reaction examination; one tested positive (2.5 %). Conclusion: This study demonstrated that there was no increased risk for appendectomies during the first wave of the pandemic. Surgeries were safe during this period. Patients continued to access the emergency service despite surgical abdominal pain and restrictive measures imposed by health authorities. The similar results observed across cohorts are attributed to the readiness of the teams and the availability of medical surgical equipment in safe quantities.

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The coronavirus disease 2019 (COVID-19) pandemic has affected healthcare systems worldwide, with mandatory quarantine and isolation measures being implemented to curb the spread of the virus. These measures have potentially led to delayed or complicated presentations of non-COVID-19 cases, including pediatric surgical cases. This study aims to evaluate pediatric surgical admission patterns, analyze the incidence of surgical diagnoses, and assess the severity of presentation during the COVID-19 period compared to the pre-COVID-19 period. This retrospective observational study was conducted at a university hospital in the eastern region of Saudi Arabia to assess the effect of the pandemic on pediatric surgery admissions patterns and severity of presentation during the COVID-19 period (March 2, 2020, to March 1, 2022) and pre-COVID-19 period (March 1, 2018, to March 1, 2020). Of the 903 pediatric surgical admissions, 366 (40.5%) presented during the COVID-19 period. The admission rate per month decreased by 6.9 during COVID-19 compared to pre-COVID-19 (mean [SD]: 21.5 [9.3] vs. 14.6 [8.2], p = 0.01). The most common admission diagnoses were appendicitis (17.5%) and inguinal hernia (15.8%). There was a 15% increase in the percentage of emergency admissions (54.4% vs. 47.3%, p = 0.037) during COVID-19 compared to pre-COVID-19. Of note, the percentage of patients admitted with acute appendicitis increased by 35.9% (20.8% vs. 15.3%, p = 0.03). Furthermore, the emergency admissions for patients with inguinal hernia doubled (26.6% vs. 12.7%, p = 0.035). No significant difference in ICU admissions, hospital length of stay, and routine discharge were observed. In conclusion, the COVID-19 pandemic correlated with a significant decrease in overall admissions and an increase in emergency admissions, including those for appendicitis and inguinal hernia. The increase in complicated conditions was not significant. There was no significant difference in ICU admissions and hospital length of stay. Future studies involving multiple centers are necessary to validate these findings.

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INTRODUCTION AND IMPORTANCE: Schistosomal appendicitis is a rare disease, with reported prevalence rates ranging from 1.31 to 3.2 %. The presented case underscores the critical significance of considering appendicular schistosomiasis as a potential etiology in cases of acute appendicitis, emphasizing the necessity of comprehensive histopathological examination for accurate diagnosis and appropriate postoperative management. CASE PRESENTATION: A 29-year-old man from Guinea, with no significant medical history, presented with vomiting, persistent abdominal pain, and fatigue over five days. Physical examination revealed signs of peritoneal irritation and imaging showed features indicative of acute appendicitis. An appendectomy was conducted laparoscopically. Histological examination confirmed gangrenous appendicitis with the presence of schistosome eggs, diagnosing acute gangrenous appendicitis with schistosomiasis. The patient recovered well postoperatively and was discharged after treatment with praziquantel. CLINICAL DISCUSSION: The clinical presentation of schistosomal appendicitis resembles that of other acute appendicitis cases. When suspicion arises due to risk factors, confirming schistosomiasis may involve serology, polymerase chain reaction assays, and identifying eggs in urine or feces. Computed tomography findings cannot distinguish acute appendicitis caused by Schistosoma species from other causes. CONCLUSIONS: Histopathological appendix analysis is crucial for detecting conditions like schistosomiasis, warranting postoperative care. Praziquantel therapy post-surgery is vital for eradicating the disease and preventing complications.

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INTRODUCTION: Non-operative management of uncomplicated appendicitis in children is a safe alternative to laparoscopic appendectomy. The purpose of this study is to determine the feasibility of nonoperative outpatient management of uncomplicated appendicitis in pediatric patients. METHODS: A standardized pathway for non-operative outpatient management of uncomplicated appendicitis in children (NOMA-C) was implemented in a university pediatric surgery practice starting October 2021. Those who met criteria would be considered for discharge from the emergency department (ED) with oral antibiotics and close followup over the following year. A quality improvement project started concurrently to monitor patients for recurrent symptoms of appendicitis. RESULTS: A total of 121 patients were diagnosed with acute appendicitis during the study period (October 2021 to April 2023). Forty-five children (38%) met criteria for the NOMA-C protocol, and 11 patients/families chose appendectomy. Of the 34 patients who pursued nonoperative management, 14 patients were admitted to the hospital and 20 patients were discharged from the ED. Total time in the ED/hospital was significantly shorter for patients discharged from the ED (7 hours versus 23 hours; p<0.001). At one year follow up only 4 (12%) had undergone appendectomy. There were no adverse events for patients who underwent nonoperative management. CONCLUSION: A protocol offering non-operative management of appendicitis with an option for outpatient management was feasible and safe. Outpatient management was associated with shorter ED/hospital stays than those admitted. Future studies should evaluate whether this protocol can be adopted by EDs without pediatric surgery services to avoid the need for transfer.

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BACKGROUND: Little is known about how COVID-19 impacted acute surgical activity for children and young people (CYP) across England. Appendicitis and testicular torsion are common surgical conditions where treatment delays can lead to avoidable complications. We undertook a retrospective national cohort study. PRIMARY AIM: To describe monthly acute surgical activity in CYP during the COVID-19 pandemic. Secondary aim: To investigate evidence of delayed diagnosis and adverse outcomes, describing variations by age and socioeconomic deprivation. METHODS: Acute hospital admissions with appendicitis or testicular pain for those under 18 were extracted using Hospital Episode Statistics. Interrupted time series modelling, Mann-Whitney and Pearson's Chi-Squared tests compared the first 14 pandemic months with the previous five years. Results were stratified by age (0-4s, 5-9s and 10-17s) and appendicitis type (all, simple and complex). RESULTS: Admissions for appendicitis and testicular torsion fell significantly early in the COVID-19 pandemic. The proportion of children with complex appendicitis also increased during this time. Orchidectomy rates rose in April 2020 for the 0-4s (+15.6% (95% CI 7.9-23.3)) and 10-17s (+11.5% (4.9-18.2)), but when the pre-pandemic period was compared with the pandemic period as a whole, there were no overall statistically significant differences in orchidectomy rates between the study periods. Overall, there was a statistically significant rise in the orchidopexy rate during the pandemic period for the 10-17s when compared with the pre-pandemic period (Pre-pandemic: 17.0% vs Pandemic: 20.9%, p < 0.0001). CONCLUSION: A consistent reduction in activity, with short-lived periods of delayed presentations during COVID-19 pandemic peaks, occurred without persisting overall increased complication rates. These results provide useful national context for smaller sized studies that reported complications due to delays in surgery. Future research could examine how reduced activity impacted other healthcare settings and treatment pathways. LEVEL OF EVIDENCE: II.

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BACKGROUND: Ultrasound (US) or magnetic resonance imaging (MRI) is recommended over computed tomography (CT) as the initial imaging modality when considering a diagnosis of appendicitis in children. This reduces unnecessary radiation exposure and has excellent accuracy. We hypothesized a significant increase in US utilization and a reduction in CT utilization in hospitals across the United States. METHODS: We retrospectively reviewed NSQIP-P data from 2015 to 2021 for patients <18 years undergoing appendectomy for acute appendicitis. Rates of US, CT, and MRI usage were compared between NSQIP-P hospitals and referring non-NSQIP-P hospitals. RESULTS: Of the 115,186 children included, 66,303 (57.6%) were imaged in NSQIP-P hospitals, 37,962 (33.0%) in non-NSQIP-P hospitals, and 7947 (6.9%) in both. US alone was used in 53.3%, followed by CT alone in 25.1%, both US + CT in 16.4%, and MRI ± CT/US in 2.6%. Non-NSIQP-P hospitals used less US than NSQIP-P centers (38.6% vs 90.8%, P < 0.0001) and more CT (74.0% vs 25.4%, P < 0.0001). From 2015 to 2021, overall US utilization increased from 68.5% to 72.3% (p < 0.0001) while CT utilization remained unchanged (43.1%-43.2%, P = 0.07). US use increased in non-NSQIP-P centers (18.8%-25.7%, P < 0.0001) but not in NSQIP-P (71.7% vs 70.9%, p = 0.28), while CT alone decreased in both (NSQIP-P: 10.1%-7.7%, P < 0.0001; non-NSQIP-P: 71.0%-59.8%, P < 0.0001). CONCLUSION: US and MRI remain underutilized in diagnosing pediatric appendicitis, especially in non-NSQIP-P hospitals. Trends show modest increase in US utilization; however, CT alone remains a highly used modality in non-NSQIP-P hospitals. Adopting diagnostic strategies from NSQIP-P centers could optimize diagnostic imaging in children. LEVEL OF EVIDENCE: III.

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BACKGROUND: The development of the human vermiform appendix at the cellular level, as well as its function, is not well understood. Appendicitis in preschool children, although uncommon, is associated with a high perforation rate and increased morbidity. METHODS: We performed single-cell RNA sequencing (scRNA-seq) on the human appendix during fetal and pediatric stages as well as preschool-age inflammatory appendices. Transcriptional features of each cell compartment were discussed in the developing appendix. Cellular interactions and differentiation trajectories were also investigated. We compared scRNA-seq profiles from preschool appendicitis to those of matched healthy controls to reveal disease-associated changes. Bulk transcriptomic data, immunohistochemistry, and real-time quantitative PCR were used to validate the findings. RESULTS: Our analysis identified 76 cell types in total and described the cellular atlas of the developing appendix. We discovered the potential role of the BMP signaling pathway in appendiceal epithelium development and identified HOXC8 and PITX2 as the specific regulons of appendix goblet cells. Higher pericyte coverage, endothelial angiogenesis, and goblet mucus scores together with lower epithelial and endothelial tight junction scores were found in the preschool appendix, which possibly contribute to the clinical features of preschool appendicitis. Preschool appendicitis scRNA-seq profiles revealed that the interleukin-17 signaling pathway may participate in the inflammation process. CONCLUSIONS: Our study provides new insights into the development of the appendix and deepens the understanding of appendicitis in preschool children.

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Amyand's hernia is defined as the presence of the appendix within an inguinal hernia sac, which is often associated with appendicitis. The association of an Amyand's hernia with an appendicular tumor has been reported in very few cases. This case report presents a 67-year-old female patient who came to the emergency department with symptoms indicative of a complicated inguinal hernia. Following surgical treatment, the diagnosis of Amyand's hernia with cecal perforation associated with an appendicular tumor was established in the context of a previous laparoscopic femoral hernia repair. The combination of these conditions has not been previously reported. The presentation of this case provides data on the clinical presentation, diagnosis, and treatment of this rare pathology that requires a high clinical suspicion to achieve a preoperative diagnosis.

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Diverticulosis of the appendix (DA) is a rare condition, often asymptomatic and incidentally discovered, with a significant association with neoplasia. The prevalence of neoplasia in specimens without DA versus those with DA was 1.28% and 26.94%, respectively. Here, we discuss a case of a 54-year-old male presented with left flank pain and dysuria. Examination showed left renal angle tenderness and leukocytosis. CT scan revealed a left ureteric stone and an enlarged appendix. The urology team placed a double-J catheter, and surgical consultation led to an appendectomy. Histopathology confirmed DA with acute inflammation, serositis, and fibroblast proliferation without malignancy. This case underscores the need to consider DA in differential diagnoses and the importance of thorough histopathological examination and timely surgical intervention.

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BACKGROUND: Acute appendicitis is one of the most common emergency abdominal disease, and recent studies have evaluated conservative treatment using antibiotics for uncomplicated appendicitis. Although the efficacy of conservative treatment for uncomplicated appendicitis is known, its efficacy for complicated appendicitis remains unknown, so are risk factors for the conservative treatment of appendicitis. In our institution, conservative treatment has long been the first choice for most appendicitis cases, except for perforation. Therefore, this novel study investigated the outcomes of conservative treatment for uncomplicated and complicated acute appendicitis and the risk factors associated with conservative treatment. AIM: To investigate the indication of conservative treatment by antibiotics for uncomplicated and complicated acute appendicitis. METHODS: We investigated 270 patients who received conservative treatment for acute appendicitis at the Nishitokyo Central General Hospital, between April 2011 and February 2022. Twenty-eight (10.3%) patients were resistant to conservative treatment and underwent surgery. We retrospectively investigated the outcomes of conservative treatment for appendicitis and the risk factors for resistance to conservative treatment using the receiver operating characteristic curves and Cox hazard model. RESULTS: Two hundred and forty-two (89.7%) patients improved with conservative treatment. The significant and independent predictors of resistance to conservative treatment were body temperature ≥ 37.3 °C, appendicolith and Douglas sinus fluid visible on computed tomography (CT). The rate of resistance to conservative treatment was 66.7% (6/9) for patients with the above three factors, 22.9% (8/35) for patients with two factors (appendicolith and body temperature ≥ 37.3 °C), 16.7% (2/12) for patients with two factors (Douglas sinus fluid and appendicolith) and 11.1% (1/9) for patients with two factors (Douglas sinus fluid and body temperature ≥ 37.3 °C). CONCLUSION: A temperature ≥ 37.3 °C, appendicolith and Douglas sinus fluid on CT might be clinical risk factors of resistance to conservative treatment for acute appendicitis.

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BACKGROUND: Pediatric appendicitis is a common cause of abdominal pain in children and is recognized as a significant surgical emergency. A prompt and accurate diagnosis is essential to prevent complications such as perforation and peritonitis. AIM: To investigate the predictive value of the systemic immune-inflammation index (SII) combined with the pediatric appendicitis score (PAS) for the assessment of disease severity and surgical outcomes in children aged 5 years and older with appendicitis. METHODS: Clinical data of 104 children diagnosed with acute appendicitis were analyzed. The participants were categorized into the acute appendicitis group and chronic appendicitis group based on disease presentation and further stratified into the good prognosis group and poor prognosis group based on prognosis. The SII and PAS were measured, and a joint model using the combined SII and PAS was constructed to predict disease severity and surgical outcomes. RESULTS: Significant differences were observed in the SII and PAS parameters between the acute appendicitis group and chronic appendicitis group. Correlation analysis showed associations among the SII, PAS, and disease severity, with the combined SII and PAS model demonstrating significant predictive value for assessing disease severity [aera under the curve (AUC) = 0.914] and predicting surgical outcomes (AUC = 0.857) in children aged 5 years and older with appendicitis. CONCLUSION: The study findings support the potential of integrating the SII with the PAS for assessing disease severity and predicting surgical outcomes in pediatric appendicitis, indicating the clinical utility of the combined SII and PAS model in guiding clinical decision-making and optimizing surgical management strategies for pediatric patients with appendicitis.