今日の臨床サポート

虫垂炎

著者: 村田篤彦 産業医科大学 公衆衛生学教室

監修: 真弓俊彦 産業医科大学 救急医学

著者校正/監修レビュー済:2021/03/24
参考ガイドライン:
  1. WSES Jerusalem guidelines for diagnosis and treatment of acute appendicitis. World J Emerg Surg. 2016 Jul 18;11:34
  1. 日本小児救急医学会:エビデンスに基づいた子どもの腹部救急診療ガイドライン2017
患者向け説明資料

概要・推奨   

  1. 急性虫垂炎の診断において右下腹部痛は重要な臨床所見である(推奨度1)
  1. 急性虫垂炎の診断において白血球およびCRP (C-reactive protein) の測定は強く推奨される(推奨度1)
  1. 急性虫垂炎の診断において泌尿器疾患の否定および確診は重要である(推奨度1)
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となりま
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧には
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧には
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧に
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となり
薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、
著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適用の査定において保険適用及び保険適用外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適用の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
村田篤彦 : 特に申告事項無し[2021年]
監修:真弓俊彦 : 特に申告事項無し[2021年]

改訂のポイント:
  1. 定期レビューを行い、Alvaradoスコアに関して加筆修正を行った。

病態・疫学・診察

疾患情報  
  1. 虫垂炎とは、虫垂の閉塞により感染が起こった病態である。小児の重症腹痛疾患のなかで最もよく認められ、全体の1~8%を占め、手術の原因となる腹部疾患のなかで最も頻度が高い。頻度の高い疾患であるが、初診時には見逃されることも少なくない。特に小児、妊婦、高齢者、免疫不全者では注意を要する。
  1. 急性虫垂炎は10歳代から20歳代に最も多くみられる腹部の急性疾患である。特に小児では、手術の原因となる腹部疾患の中で最も頻度が高い。
問診・診察のポイント  
ポイント:
  1. 典型的な急性虫垂炎では右下腹部痛が認められるが、初期の場合、認められない症例が多数ある。その場合、心窩部痛、嘔吐、微熱など急性胃腸炎に類似した症状を認めることがある。それらの症状を認めた場合は常に急性虫垂炎を念頭に置く。

これより先の閲覧には個人契約のトライアルまたはお申込みが必要です。

最新のエビデンスに基づいた二次文献データベース「今日の臨床サポート」。
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文献 

著者: John M Howell, Orin L Eddy, Thomas W Lukens, Molly E W Thiessen, Scott D Weingart, Wyatt W Decker, American College of Emergency Physicians
雑誌名: Ann Emerg Med. 2010 Jan;55(1):71-116. doi: 10.1016/j.annemergmed.2009.10.004.
Abstract/Text This clinical policy from the American College of Emergency Physicians is an update of a 2000 clinical policy on the evaluation and management of patients presenting with nontraumatic acute abdominal pain.1 A writing subcommittee reviewed the literature to derive evidence-based recommendations to help clinicians answer the following critical questions: (1)Can clinical findings be used to guide decision making in the risk stratification of patients with possible appendicitis? (2) In adult patients with suspected acute appendicitis who are undergoing a computed tomography scan, what is the role of contrast? (3) In children with suspected acute appendicitis who undergo diagnostic imaging, what are the roles of computed tomography and ultrasound in diagnosing acute appendicitis?Evidence was graded and recommendations were given based on the strength of the available data in the medical literature.

PMID 20116016  Ann Emerg Med. 2010 Jan;55(1):71-116. doi: 10.1016/j.an・・・
著者: J M Wagner, W P McKinney, J L Carpenter
雑誌名: JAMA. 1996 Nov 20;276(19):1589-94.
Abstract/Text Appendicitis is a common cause of abdominal pain for which prompt diagnosis is rewarded by a marked decrease in morbidity and mortality. The history and physical examination are at least as accurate as any laboratory modality in diagnosing or excluding appendicitis. Those signs and symptoms most helpful in diagnosing or excluding appendicitis are reviewed. The presence of a positive psoas sign, fever, or migratory pain to the right lower quadrant suggests an increased likelihood of appendicitis. Conversely, the presence of vomiting before pain makes appendicitis unlikely. The lack of the classic migration of pain, right lower quadrant pain, guarding, or fever makes appendicitis less likely. This article reviews the literature evaluating the operating characteristics of the most useful elements of the history and physical examination for the diagnosis of appendicitis.

PMID 8918857  JAMA. 1996 Nov 20;276(19):1589-94.
著者: J Golledge, A P Toms, I J Franklin, M W Scriven, R B Galland
雑誌名: Ann R Coll Surg Engl. 1996 Jan;78(1):11-4.
Abstract/Text The aim of this study was to evaluate the accuracy of different methods of demonstrating right iliac fossa peritonism in appendicitis. The methods used were cat's eye symptom (pain on going over a bump in the road), cough sign, right iliac fossa tenderness, percussion tenderness, rebound tenderness and guarding. A series of 100 consecutive patients with a median age of 25 years (range 4-81 years), presenting with right iliac fossa pain were studied prospectively; the male:female ratio was 39:61. In all, 58 patients underwent operation, 44 had appendicitis confirmed on histology. Fourteen patients had a normal appendix removed; 11 were women aged between 16 and 45 years. Cat's eye symptom and cough sign were sensitive indicators of appendicitis (sensitivity 0.80 and 0.82, respectively), but were not specific (specificity 0.52 and 0.50, respectively) and therefore inaccurate (accuracy 64%). Percussion tenderness was less sensitive (sensitivity 0.57) but more specific (specificity 0.86). Rebound tenderness proved to be sensitive (sensitivity 0.82), specific (specificity 0.89) and accurate (accuracy 86%). Thus, rebound tenderness had a positive predictive value of 86% compared with 56% and 57% for cough sign and cat's eye symptom, respectively. In the difficult diagnostic group of young women, the positive predictive value of rebound tenderness was 88% compared with 58% and 56% for cat's eye symptom and cough sign. Appendicitis remains a difficult diagnosis, particularly in young women. Rebound tenderness still has an important role to play in clinical assessment.

PMID 8659965  Ann R Coll Surg Engl. 1996 Jan;78(1):11-4.
著者: R E Andersson, A P Hugander, S H Ghazi, H Ravn, S K Offenbartl, P O Nyström, G P Olaison
雑誌名: World J Surg. 1999 Feb;23(2):133-40.
Abstract/Text The clinical diagnosis of appendicitis needs to be improved, as up to 40% of explorations for suspected appendicitis are unnecessary. The use of body temperature and laboratory examinations as diagnostic aids in the management of these patients is controversial. The diagnostic power of these variables compared to that of the disease history and clinical findings is not well studied. In this study we prospectively assessed and compared the diagnostic value of 21 elements of the history, clinical findings, body temperature, and laboratory examinations in 496 patients with suspected appendicitis. The diagnostic value of each variable was compared from the area under the receiver operating characteristic (ROC) curve and the likelihood ratios (LR). Logistic regression was used to analyze the diagnostic value of a combination of variables and to analyze independent relations. No single variable had sufficiently high discriminating or predicting power to be used as a true diagnostic test. The inflammatory variables (temperature, leukocyte and differential white blood cell (WBC) counts, C-reactive protein) had discriminating and predicting powers similar to those of the clinical findings (direct and rebound abdominal tenderness and guarding). Anorexia, nausea, and right-sided rectal tenderness had no diagnostic value. The leukocyte and differential WBC counts, C-reactive protein, rebound tenderness, guarding, and gender were independent predictors of appendicitis with a combined ROC area of 0. 93 for appendicitis. This showed that inflammatory variables contain important diagnostic information, especially with advanced appendicitis. They should therefore always be included in the diagnostic workup in patients with suspected appendicitis.

PMID 9880421  World J Surg. 1999 Feb;23(2):133-40.
著者: R Lane, J Grabham
雑誌名: Ann R Coll Surg Engl. 1997 Mar;79(2):128-9.
Abstract/Text
PMID 9135241  Ann R Coll Surg Engl. 1997 Mar;79(2):128-9.
著者: J R Izbicki, W T Knoefel, D K Wilker, H K Mandelkow, K Müller, M Siebeck, L Schweiberer
雑誌名: Eur J Surg. 1992 Apr;158(4):227-31.
Abstract/Text OBJECTIVE: To formulate a score system that would make the preoperative diagnosis of acute appendicitis more accurate.
DESIGN: Retrospective then prospective study.
SETTING: City University Hospital.
SUBJECTS: 536 patients who had their appendixes removed between 1981 and 1986 (retrospective study), and 150 consecutive patients admitted with a presumptive diagnosis of appendicitis between 1987 and 1988 (prospective study).
MAIN OUTCOME MEASURES: Correlation between the histological diagnosis of appendicitis and variables representing history, clinical examination, and laboratory investigations.
RESULTS: The rate of histologically proven negative appendicectomies in the retrospective series was 40% and in the prospective series 33%. The variables that were thought to be predictive were: male sex, white cell count of greater than 11 x 10(9)/l, history of less than 24 hours with no previous complaints, rebound tenderness, shift of pain from the epigastrium, and localised guarding, but all criteria had low specificities and sensitivities when applied prospectively, and combining the scores did not improve them.
CONCLUSION: The accurate diagnosis of appendicitis depends largely on the experience of the surgeon and is not improved by the application of a score system that includes the above variables.

PMID 1352137  Eur J Surg. 1992 Apr;158(4):227-31.
著者: M Y Alshehri, A Ibrahim, N Abuaisha, T Malatani, S Abu-Eshy, S Khairulla, K Bahamdan
雑誌名: East Afr Med J. 1995 Aug;72(8):504-6.
Abstract/Text This is a prospective study on 123 randomly selected patients admitted with the diagnosis of acute appendicitis. The value of rebound tenderness as a clinical diagnostic tool was statistically compared to those of some other physical signs; namely guarding, rigidity and Rovsing's sign. Rebound tenderness was found to carry the highest sensitivity (94.7%), negative predictive value (81.3%), reliability (49.1%), and association with histological diagnosis (P < 0.05). However, its specificity and positive predictive value was not significantly different from those of other physical signs. It is concluded that, in contradistinction to some previously published reports, our study emphasizes the role of rebound tenderness in the clinical diagnosis of acute appendicitis.

PMID 7588144  East Afr Med J. 1995 Aug;72(8):504-6.
著者: H Jahn, F K Mathiesen, K Neckelmann, C P Hovendal, T Bellstrøm, F Gottrup
雑誌名: Eur J Surg. 1997 Jun;163(6):433-43.
Abstract/Text OBJECTIVE: To evaluate the diagnostic accuracy of clinical judgment and diagnostic ultrasonography (US) used routinely and to create a scoring system to aid diagnosis.
DESIGN: Prospective, double-blind study.
SETTING: University hospital, Denmark.
SUBJECTS: 222 Consecutive patients suspected of having acute appendicitis admitted between 0800 and midnight from June 1990 to June 1992.
INTERVENTIONS: 148 Patients (67%) underwent appendicectomy and the remaining 74 patients were observed. 193 Patients (87%) had a diagnostic US examination. 21 Predictive variables were collected prospectively to create a scoring system.
MAIN OUTCOME MEASURES: Results of surgical pathological findings, clinical outcome (observed group), diagnostic US, and values of diagnostic score.
RESULTS: The decision to operate was made by a junior surgeon solely on the clinical examination, which yielded a diagnostic accuracy of 76%, specificity of 58%, and negative appendicectomy rate of 36%. 193 Patients underwent diagnostic US conducted by the radiologist on call of whom 123 were operated on, 78 for histologically proven appendicitis. US had a diagnostic accuracy of 72%, sensitivity of 49%, and specificity of 88%. Of the 21 predictive factors for acute appendicitis 11 were significant (p < 0.05): total white cell count (WCC) (>10 x 10[9]/1), migration of pain to the right lower quadrant, gradual onset of pain, increasing intensity of pain, pain aggravated by movement, pain aggravated by coughing, anorexia, vomiting, indirect tenderness (Rovsing's sign), muscle spasm, and sex. These 11 predictors were assigned an appropriate weight, based on the likelihood ratio, and used to create a scoring system. The score performed poorly if it was used to separate patients for observation and those for appendicectomy. However, if the score was used with two cut-off points resulting in three test zones (low, intermediate, and high risk of having acute appendicitis), some diagnostic benefit was seen for those patients within the zones of high and low probability.
CONCLUSION: The clinical judgment of a junior surgeon was disappointing, and diagnostic aids are desirable to reduce the negative appendicectomy rate. Diagnostic US performed poorly as a routine procedure. Application of an up to date scoring system might be of some help to patients with a high or low probability of acute appendicitis, but any conclusion about its clinical application cannot be drawn from this study.

PMID 9231855  Eur J Surg. 1997 Jun;163(6):433-43.
著者: J Berry, R A Malt
雑誌名: Ann Surg. 1984 Nov;200(5):567-75.
Abstract/Text In an analysis of the first 72 cases treated after the formulation of the appendicitis syndrome in 1886 compared with the experience from 1929-1959 and with 307 randomly selected recent cases, the major therapeutic trend has been an emphasis on appendectomy before perforation and abscess formation occur. The rate of infection nonetheless remains approximately 17%. Although the overall mortality rate has declined from 26% overall (40% for surgery) to 0.8%, the current rate of perforation is 28%, with a diagnostic accuracy of 82%. Among 13,848 patients from several reports the perforation rate increases linearly with diagnostic accuracy; therefore, a balance must be sought. Delay awaiting a diagnosis is a major determinant of perforation, but diagnostic aids are of limited help. Clinical acuity and prudent decisiveness are the keys to proper action.

PMID 6385879  Ann Surg. 1984 Nov;200(5):567-75.
著者: H John, U Neff, M Kelemen
雑誌名: World J Surg. 1993 Mar-Apr;17(2):243-9.
Abstract/Text A total of 111 patients referred with a diagnosis of suspected "appendicitis" were entered into a prospective study. The surgeon and radiologist in charge of ultrasonography made separate diagnoses, and their findings were then combined and discussed as indications for surgery. Clinically, a history of pain migration proved to be reliable (p < 0.0001) as a diagnostic indicator, in contrast to nausea and initial irregularity of bowels. The duration of symptoms was significantly shorter in patients with proved appendicitis than among patients with negative findings (median 24 hours compared with 41 hours, p < 0.04). Among patients with perforated appendicitis, the symptomatic history was prolonged (not significantly) by 3 hours. Peritoneal signs such as pain on percussion, rebound tenderness, guarding, and a leukocytosis of more than 13,000/mm3 were indicative of appendicitis (p = 0.0001 for each sign). Lively bowel sounds excluded the possibility of appendicitis (p = 0.001). Scanty bowel sounds, rectal tenderness, axillorectal temperature difference, and a left shift in leukocytes were of no diagnostic significance. The doctor's "clinical experience" is significant at the level of p < 0.03. On ultrasonography, the following signs were indicative of appendicitis: periappendicular infiltration (p = 0.0003), a visible "cockade," and an appendix larger than 12 mm in diameter (p = 0.04). For 75% of the patients the surgeon was sure of his own clinical diagnosis and did not allow himself to be influenced by the sonographic findings. In 12% of doubtful cases ultrasonographic results decisively favored operation, and in 4.5% (n = 5) it prevented an unnecessary laparotomy in the presence of positive clinical symptoms.(ABSTRACT TRUNCATED AT 250 WORDS)

PMID 8511921  World J Surg. 1993 Mar-Apr;17(2):243-9.
著者: G B Markle
雑誌名: Am J Surg. 1973 Jun;125(6):721-2.
Abstract/Text
PMID 4710195  Am J Surg. 1973 Jun;125(6):721-2.
著者: C-W Yu, L-I Juan, M-H Wu, C-J Shen, J-Y Wu, C-C Lee
雑誌名: Br J Surg. 2013 Feb;100(3):322-9. doi: 10.1002/bjs.9008. Epub 2012 Nov 30.
Abstract/Text BACKGROUND: The aim was to evaluate the diagnostic value of procalcitonin, C-reactive protein (CRP) and white blood cell count (WBC) in uncomplicated or complicated appendicitis by means of a systematic review and meta-analysis.
METHODS: The Embase, MEDLINE and Cochrane databases were searched, along with reference lists of relevant articles, without language restriction, to September 2012. Original studies were selected that reported the performance of procalcitonin alone or in combination with CRP or WBC in diagnosing appendicitis. Test performance characteristics were summarized using hierarchical summary receiver operating characteristic (ROC) curves and bivariable random-effects models.
RESULTS: Seven qualifying studies (1011 suspected cases, 636 confirmed) from seven countries were identified. Bivariable pooled sensitivity and specificity were 33 (95 per cent confidence interval (c.i.) 21 to 47) and 89 (78 to 95) per cent respectively for procalcitonin, 57 (39 to 73) and 87 (58 to 97) per cent for CRP, and 62 (47 to 74) and 75 (55 to 89) per cent for WBC. ROC curve analysis showed that CRP had the highest accuracy (area under ROC curve 0·75, 95 per cent c.i. 0·71 to 0·78), followed by WBC (0·72, 0·68 to 0·76) and procalcitonin (0·65, 0·61 to 0·69). Procalcitonin was found to be more accurate in diagnosing complicated appendicitis, with a pooled sensitivity of 62 (33 to 84) per cent and specificity of 94 (90 to 96) per cent.
CONCLUSION: Procalcitonin has little value in diagnosing acute appendicitis, with lower diagnostic accuracy than CRP and WBC. However, procalcitonin has greater diagnostic value in identifying complicated appendicitis. Given the imperfect accuracy of these three variables, new markers for improving medical decision-making in patients with suspected appendicitis are highly desirable.

Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.
PMID 23203918  Br J Surg. 2013 Feb;100(3):322-9. doi: 10.1002/bjs.9008・・・
著者: C P Macklin, G S Radcliffe, J M Merei, M D Stringer
雑誌名: Ann R Coll Surg Engl. 1997 May;79(3):203-5.
Abstract/Text The accuracy of the modified Alvarado score was assessed prospectively in the preoperative diagnosis of acute appendicitis in children. A consecutive series of 118 patients (54 boys, 64 girls) with acute abdominal pain was studied prospectively over a 6 month period. Appendicitis was confirmed in 38 of 43 children undergoing appendicectomy, giving a false-positive appendicectomy rate of 11.6%. No child under active observation was subsequently found to have a perforated appendix. The overall sensitivity of a modified Alvarado score of > or = 7 was 76.3% and its specificity was 78.8%. Current clinical practice is more accurate than the modified Alvarado score in the diagnosis of acute appendicitis in children.

PMID 9196342  Ann R Coll Surg Engl. 1997 May;79(3):203-5.
著者: Winson Jianhong Tan, Sanchalika Acharyya, Yaw Chong Goh, Weng Hoong Chan, Wai Keong Wong, London Lucien Ooi, Hock Soo Ong
雑誌名: J Am Coll Surg. 2015 Feb;220(2):218-24. doi: 10.1016/j.jamcollsurg.2014.10.010. Epub 2014 Oct 25.
Abstract/Text BACKGROUND: Although computed tomography (CT) has reduced negative appendectomy rates, its radiation risk remains a concern. We compared the performance statistics of the Alvarado Score (AS) with those of CT scan in the evaluation of suspected appendicitis, with the aim of identifying a subset of patients who will benefit from CT evaluation.
STUDY DESIGN: We performed prospective data collection on 350 consecutive patients with suspected appendicitis who were evaluated with CT scans. The AS for each patient was scored at admission and correlated with eventual histology and CT findings. The sensitivity, specificity, and positive likelihood ratios were determined for various AS and for CT scan. The AS ranges that benefitted most from CT evaluation were determined by comparing the positive likelihood ratios of CT scan with each of the AS cutoff values.
RESULTS: The study included 134 males (38.3%) and 216 females (61.7%). The overall prevalence of appendicitis was 44.3% in the total study population; 37.5% in females and 55.2% in males. There were 168 patients (48%) who underwent surgery, with a negative appendectomy rate of 7.7%. Positive likelihood ratio of disease was significantly greater than 1 only in patients with an AS of 4 and above. An AS of 7 and above in males and 9 and above in females has a positive likelihood ratio comparable to that of CT scan.
CONCLUSIONS: Evaluation by CT is beneficial mainly in patients with AS of 6 and below in males and 8 and below in females. We propose an objective management algorithm with the AS guiding subsequent evaluation.

Copyright © 2015 American College of Surgeons. Published by Elsevier Inc. All rights reserved.
PMID 25488354  J Am Coll Surg. 2015 Feb;220(2):218-24. doi: 10.1016/j.・・・
著者: S M M de Castro, C Ünlü, E Ph Steller, B A van Wagensveld, B C Vrouenraets
雑誌名: World J Surg. 2012 Jul;36(7):1540-5. doi: 10.1007/s00268-012-1521-4.
Abstract/Text BACKGROUND: Acute appendicitis is still a difficult diagnosis. Scoring systems are designed to aid in the clinical assessment of patients with acute appendicitis. The Alvarado score is the most well known and best performing in validation studies. The purpose of the present study was to externally validate a recently developed appendicitis inflammatory response (AIR) score and compare it to the Alvarado score.
METHODS: The present study selected consecutive patients who presented with suspicion of acute appendicitis between 2006 and 2009. Variables necessary to evaluate the scoring systems were registered. The diagnostic performance of the two scores was compared.
RESULTS: The present study included 941 consecutive patients with suspicion of acute appendicitis. There were 410 male patients (44%) and 531 female patients (56%). The area under the receiver operating characteristic curve of the AIR score was 0.96 and significantly better than the area under the curve of 0.82 of the Alvarado score (p < 0.05). The AIR score also outperformed the Alvarado score when analyzing the more difficult patients, including women, children, and the elderly.
CONCLUSIONS: This study externally validates the AIR Score for patients with acute appendicitis. The scoring system has a high discriminating power and outperforms the Alvarado score.

PMID 22447205  World J Surg. 2012 Jul;36(7):1540-5. doi: 10.1007/s0026・・・
著者: R E B Andersson
雑誌名: Br J Surg. 2004 Jan;91(1):28-37. doi: 10.1002/bjs.4464.
Abstract/Text BACKGROUND: The importance of specific elements in the clinical diagnosis of appendicitis is controversial. This review analyses the diagnostic value of elements of disease history, clinical findings and laboratory test results in suspected appendicitis.
METHODS: A systematic Medline search was made of all published studies on the clinical and laboratory diagnosis of appendicitis in patients admitted to hospital with suspected disease. Meta-analyses of receiver-operator characteristic (ROC) areas, and positive and negative likelihood ratios, of 28 diagnostic variables described in 24 studies are presented.
RESULTS: Inflammatory response variables (granulocyte count, proportion of polymorphonuclear blood cells, white blood cell count and C-reactive protein concentration), descriptors of peritoneal irritation (rebound and percussion tenderness, guarding and rigidity) and migration of pain were the strongest discriminators, with ROC areas of 0.78 to 0.68. The discriminatory power of the inflammatory variables was particularly strong for perforated appendicitis, with ROC areas of 0.85 to 0.87. Appendicitis was likely when two or more inflammatory variables were increased and unlikely when all were normal.
CONCLUSION: Although all clinical and laboratory variables are weak discriminators individually, they achieve a high discriminatory power when combined. Laboratory examination of the inflammatory response, clinical descriptors of peritoneal irritation, and a history of migration of pain yield the most important diagnostic information and should be included in any diagnostic assessment.

Copyright 2004 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.
PMID 14716790  Br J Surg. 2004 Jan;91(1):28-37. doi: 10.1002/bjs.4464.・・・
著者: S Hallan, A Asberg
雑誌名: Scand J Clin Lab Invest. 1997 Aug;57(5):373-80.
Abstract/Text The aim of the study was to review the literature on the accuracy of C-reactive protein (CRP) in diagnosing acute appendicitis. All the relevant articles found by searching Medline and the Science Citation Index were reviewed. We used summary receiver operating characteristic (SROC) curve analysis to describe the central tendency of the studies and to assess potential sources of variability. We included 22 articles with a total number of 3436 patients. The sensitivity ranged from 0.40 to 0.99, and the specificity from 0.27 to 0.90. The cut-off values for a positive test varied from 5 to 25 mg l-1. SROC curve analysis showed that CRP performed significantly better in acute abdomen populations (11 studies) than in populations already selected for appendectomy (11 studies). The diagnostic accuracy of CRP tended to be a little inferior to that of total leukocyte count (13 studies). CRP is a test of medium accuracy in diagnosing acute appendicitis. The formerly distractingly wide range of sensitivity and specificity is at least partly due to variations in cut-off values and to differences in study populations. However, definitive conclusions on the clinical usefulness of the test could not be drawn.

PMID 9279962  Scand J Clin Lab Invest. 1997 Aug;57(5):373-80.
著者: Teruhiko Terasawa, C Craig Blackmore, Stephen Bent, R Jeffrey Kohlwes
雑誌名: Ann Intern Med. 2004 Oct 5;141(7):537-46.
Abstract/Text BACKGROUND: Although clinicians commonly use computed tomography or ultrasonography to diagnose acute appendicitis, the accuracy of these imaging tests remains unclear.
PURPOSE: To review the diagnostic accuracy of computed tomography and ultrasonography in adults and adolescents with suspected acute appendicitis.
DATA SOURCES: The authors used MEDLINE, EMBASE, bibliographies, review articles, textbooks, and expert opinion to retrieve English- and non-English-language articles published from 1966 to December 2003.
STUDY SELECTION: The authors included prospective studies evaluating computed tomography or ultrasonography followed by surgical confirmation or clinical follow-up in patients at least 14 years of age with suspected appendicitis.
DATA EXTRACTION: One assessor (for non-English-language studies) or 2 assessors (for English-language studies) independently reviewed each article to abstract relevant study characteristics and results.
DATA SYNTHESIS: Twelve computed tomography studies and 14 ultrasonography studies met inclusion criteria. Computed tomography had an overall sensitivity of 0.94 (95% CI, 0.91 to 0.95), a specificity of 0.95 (CI, 0.93 to 0.96), a positive likelihood ratio of 13.3 (CI, 9.9 to 17.9), and a negative likelihood ratio of 0.09 (CI, 0.07 to 0.12). Ultrasonography had an overall sensitivity of 0.86 (CI, 0.83 to 0.88), a specificity of 0.81 (CI, 0.78 to 0.84), a positive likelihood ratio of 5.8 (CI, 3.5 to 9.5), and a negative likelihood ratio of 0.19 (CI, 0.13 to 0.27). Verification bias and inappropriate blinding of reference standards were noted in all of the included studies.
LIMITATIONS: The summary assessment of the diagnostic accuracy for both tests was limited by the small number of studies, heterogeneity among study samples, and poor methodologic quality in the original studies.
CONCLUSIONS: Computed tomography is probably more accurate than ultrasonography for diagnosing appendicitis in adults and adolescents. Prospective studies that apply gold standard diagnostic testing to all study participants would more reliably estimate the true diagnostic accuracy of these tests.

PMID 15466771  Ann Intern Med. 2004 Oct 5;141(7):537-46.
著者: Andrea S Doria, Rahim Moineddin, Christian J Kellenberger, Monica Epelman, Joseph Beyene, Suzanne Schuh, Paul S Babyn, Paul T Dick
雑誌名: Radiology. 2006 Oct;241(1):83-94. doi: 10.1148/radiol.2411050913. Epub 2006 Aug 23.
Abstract/Text PURPOSE: To perform a meta-analysis to evaluate the diagnostic performance of ultrasonography (US) and computed tomography (CT) for the diagnosis of appendicitis in pediatric and adult populations.
MATERIALS AND METHODS: Medical literature (from 1986 to 2004) was searched for articles on studies that used US, CT, or both as diagnostic tests for appendicitis in children (26 studies, 9356 patients) or adults (31 studies, 4341 patients). Prospective and retrospective studies were included if they separately reported the rate of true-positive, true-negative, false-positive, and false-negative diagnoses of appendicitis from US and CT findings compared with the positive and negative rates of appendicitis at surgery or follow-up. Clinical variables, technical factors, and test performance were extracted. Three readers assessed the quality of studies.
RESULTS: Pooled sensitivity and specificity for diagnosis of appendicitis in children were 88% (95% confidence interval [CI]: 86%, 90%) and 94% (95% CI: 92%, 95%), respectively, for US studies and 94% (95% CI: 92%, 97%) and 95% (95% CI: 94%, 97%), respectively, for CT studies. Pooled sensitivity and specificity for diagnosis in adults were 83% (95% CI: 78%, 87%) and 93% (95% CI: 90%, 96%), respectively, for US studies and 94% (95% CI: 92%, 95%) and 94% (95% CI: 94%, 96%), respectively, for CT studies.
CONCLUSION: From the diagnostic performance perspective, CT had a significantly higher sensitivity than did US in studies of children and adults; from the safety perspective, however, one should consider the radiation associated with CT, especially in children.

(c) RSNA, 2006.
PMID 16928974  Radiology. 2006 Oct;241(1):83-94. doi: 10.1148/radiol.2・・・
著者: R Obermaier, S Benz, M Asgharnia, R Kirchner, U T Hopt
雑誌名: Eur J Med Res. 2003 Oct 22;8(10):451-6.
Abstract/Text OBJECTIVE: The value of ultrasound in the diagnosis of acute appendicitis is still unclear. Both, studies with excellent and such with disappointing results have been published. The aim of this investigation was to answer the question, whether the results of these studies depend on study design, the investigating clinical department, or the number of ultrasound investigators.
METHODS: A systematic literature research (PubMed (NLM) database) was performed. Of 99 publications dealing with ultrasound in the diagnosis of acute appendicitis, 69 were relevant to investigate the value of ultrasound in suspected appendicitis.
RESULTS: Results of single-center studies (sensitivity 81.6%, specificity 89.8%, accuracy 85.7%) are better then those of multi-center trials (38.3%, 87.6%, 62.9%). There are no distinct differences between the investigating departments (surgeons 78.9%, 88.9%, 86.0%; radiologists 83.1%, 88.1%, 83.5%; mixed 77.8%, 87.1%, 79.4%, no specification 73.8%, 87.1%, 80.45.9%). Less than 10 investigators showed better diagnostic values (84.3%, 86.8%, 85.6%) compared to studies with 10 or more investigators (64.7%, 88.6%, 67.7%).
CONCLUSION: The results of multi-center trials are disappointing and the good results of single-center studies do not reflect surgical everyday life. However, excellent results can be obtained if the investigation is restricted to a few specialists irrespectively of the clinical department.

PMID 14594651  Eur J Med Res. 2003 Oct 22;8(10):451-6.
著者: Veronica Hlibczuk, Judith A Dattaro, Zhezhen Jin, Louise Falzon, Michael D Brown
雑誌名: Ann Emerg Med. 2010 Jan;55(1):51-59.e1. doi: 10.1016/j.annemergmed.2009.06.509. Epub 2009 Sep 5.
Abstract/Text STUDY OBJECTIVE: We seek to determine the diagnostic test characteristics of noncontrast computed tomography (CT) for appendicitis in the adult emergency department (ED) population.
METHODS: We conducted a search of MEDLINE, EMBASE, the Cochrane Library, and the bibliographies of previous systematic reviews. Included studies assessed the diagnostic accuracy of noncontrast CT for acute appendicitis in adults by using the final diagnosis at surgery or follow-up at a minimum of 2 weeks as the reference standard. Studies were included only if the CT was completed using a multislice helical scanner. Two authors independently conducted the relevance screen of titles and abstracts, selected studies for the final inclusion, extracted data, and assessed study quality. Consensus was reached by conference, and any disagreements were adjudicated by a third reviewer. Unenhanced CT test performance was assessed with summary receiver operating characteristic curve analysis, with independently pooled sensitivity and specificity values across studies.
RESULTS: The search yielded 1,258 publications; 7 studies met the inclusion criteria and provided a sample of 1,060 patients. The included studies were of high methodological quality with respect to appropriate patient spectrum and reference standard. Our pooled estimates for sensitivity and specificity were 92.7% (95% confidence interval 89.5% to 95.0%) and 96.1% (95% confidence interval 94.2% to 97.5%), respectively; the positive likelihood ratio=24 and the negative likelihood ratio=0.08.
CONCLUSION: We found the diagnostic accuracy of noncontrast CT for the diagnosis of acute appendicitis in the adult population to be adequate for clinical decisionmaking in the ED setting.

Copyright 2009 American College of Emergency Physicians. Published by Mosby, Inc. All rights reserved.
PMID 19733421  Ann Emerg Med. 2010 Jan;55(1):51-59.e1. doi: 10.1016/j.・・・
著者: Bo Rud, Thomas S Vejborg, Eli D Rappeport, Johannes B Reitsma, Peer Wille-Jørgensen
雑誌名: Cochrane Database Syst Rev. 2019 Nov 19;2019(11). doi: 10.1002/14651858.CD009977.pub2. Epub 2019 Nov 19.
Abstract/Text BACKGROUND: Diagnosing acute appendicitis (appendicitis) based on clinical evaluation, blood testing, and urinalysis can be difficult. Therefore, in persons with suspected appendicitis, abdominopelvic computed tomography (CT) is often used as an add-on test following the initial evaluation to reduce remaining diagnostic uncertainty. The aim of using CT is to assist the clinician in discriminating between persons who need surgery with appendicectomy and persons who do not.
OBJECTIVES: Primary objective Our primary objective was to evaluate the accuracy of CT for diagnosing appendicitis in adults with suspected appendicitis. Secondary objectives Our secondary objectives were to compare the accuracy of contrast-enhanced versus non-contrast-enhanced CT, to compare the accuracy of low-dose versus standard-dose CT, and to explore the influence of CT-scanner generation, radiologist experience, degree of clinical suspicion of appendicitis, and aspects of methodological quality on diagnostic accuracy.
SEARCH METHODS: We searched MEDLINE, Embase, and Science Citation Index until 16 June 2017. We also searched references lists. We did not exclude studies on the basis of language or publication status.
SELECTION CRITERIA: We included prospective studies that compared results of CT versus outcomes of a reference standard in adults (> 14 years of age) with suspected appendicitis. We excluded studies recruiting only pregnant women; studies in persons with abdominal pain at any location and with no particular suspicion of appendicitis; studies in which all participants had undergone ultrasonography (US) before CT and the decision to perform CT depended on the US outcome; studies using a case-control design; studies with fewer than 10 participants; and studies that did not report the numbers of true-positives, false-positives, false-negatives, and true-negatives. Two review authors independently screened and selected studies for inclusion.
DATA COLLECTION AND ANALYSIS: Two review authors independently collected the data from each study and evaluated methodological quality according to the Quality Assessment of Studies of Diagnostic Accuracy - Revised (QUADAS-2) tool. We used the bivariate random-effects model to obtain summary estimates of sensitivity and specificity.
MAIN RESULTS: We identified 64 studies including 71 separate study populations with a total of 10,280 participants (4583 with and 5697 without acute appendicitis). Estimates of sensitivity ranged from 0.72 to 1.0 and estimates of specificity ranged from 0.5 to 1.0 across the 71 study populations. Summary sensitivity was 0.95 (95% confidence interval (CI) 0.93 to 0.96), and summary specificity was 0.94 (95% CI 0.92 to 0.95). At the median prevalence of appendicitis (0.43), the probability of having appendicitis following a positive CT result was 0.92 (95% CI 0.90 to 0.94), and the probability of having appendicitis following a negative CT result was 0.04 (95% CI 0.03 to 0.05). In subgroup analyses according to contrast enhancement, summary sensitivity was higher for CT with intravenous contrast (0.96, 95% CI 0.92 to 0.98), CT with rectal contrast (0.97, 95% CI 0.93 to 0.99), and CT with intravenous and oral contrast enhancement (0.96, 95% CI 0.93 to 0.98) than for unenhanced CT (0.91, 95% CI 0.87 to 0.93). Summary sensitivity of CT with oral contrast enhancement (0.89, 95% CI 0.81 to 0.94) and unenhanced CT was similar. Results show practically no differences in summary specificity, which varied from 0.93 (95% CI 0.90 to 0.95) to 0.95 (95% CI 0.90 to 0.98) between subgroups. Summary sensitivity for low-dose CT (0.94, 95% 0.90 to 0.97) was similar to summary sensitivity for standard-dose or unspecified-dose CT (0.95, 95% 0.93 to 0.96); summary specificity did not differ between low-dose and standard-dose or unspecified-dose CT. No studies had high methodological quality as evaluated by the QUADAS-2 tool. Major methodological problems were poor reference standards and partial verification primarily due to inadequate and incomplete follow-up in persons who did not have surgery.
AUTHORS' CONCLUSIONS: The sensitivity and specificity of CT for diagnosing appendicitis in adults are high. Unenhanced standard-dose CT appears to have lower sensitivity than standard-dose CT with intravenous, rectal, or oral and intravenous contrast enhancement. Use of different types of contrast enhancement or no enhancement does not appear to affect specificity. Differences in sensitivity and specificity between low-dose and standard-dose CT appear to be negligible. The results of this review should be interpreted with caution for two reasons. First, these results are based on studies of low methodological quality. Second, the comparisons between types of contrast enhancement and radiation dose may be unreliable because they are based on indirect comparisons that may be confounded by other factors.

Copyright © 2019 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
PMID 31743429  Cochrane Database Syst Rev. 2019 Nov 19;2019(11). doi: ・・・
著者: Richard L Barger, Kiran R Nandalur
雑誌名: Acad Radiol. 2010 Oct;17(10):1211-6. doi: 10.1016/j.acra.2010.05.003. Epub 2010 Jul 15.
Abstract/Text RATIONALE AND OBJECTIVES: Perform a meta-analysis evaluating the diagnostic performance of magnetic resonance imaging (MRI) for the diagnosis of acute appendicitis.
MATERIALS AND METHODS: MEDLINE and EMBASE were queried between January 1995 and December 2009. Prospective and retrospective studies were included if they: used MRI as a diagnostic test for appendicitis, used pathology or clinical follow-up as the reference standard, and reported absolute number of true-positive, true-negative, false-positive, and false-negative results, or stated sufficient data to derive these values. Summary sensitivity, summary specificity, positive and negative likelihood ratios (LR+) and (LR-), and diagnostic odds ratio were calculated. Heterogeneity of the results was assessed using Forest plots and the value of inconsistency index (I(2)).
RESULTS: The inclusion criteria were fulfilled by eight articles with a total of 363 patients (mean age 26.9 ± 7.2 years; 86.2 % female). The appendix was not found in eight patients, with one article not reporting such data. The summary sensitivity was 97% (92%-99% at 95% confidence interval [CI]) and summary specificity was 95% (CI: 94%-99%), with a LR+ of 16.3 (CI: 9.1-29.1) and a LR- of 0.09 (CI: 0.04-0.197). Diagnostic odds ratio was 299.85 (CI: 97.5-921.61). No heterogeneity was found in the sensitivity (I(2) = 0.0, P = .4589). Minimal heterogeneity was found in the specificity (I(2) = 21.9%, P = .2553).
CONCLUSION: MRI appears promising in the evaluation of acute appendicitis, although larger future studies are warranted to confirm the results.

Copyright © 2010 AUR. Published by Elsevier Inc. All rights reserved.
PMID 20634107  Acad Radiol. 2010 Oct;17(10):1211-6. doi: 10.1016/j.acr・・・
著者: S L Lee, A J Walsh, H S Ho
雑誌名: Arch Surg. 2001 May;136(5):556-62.
Abstract/Text HYPOTHESIS: Computed tomography (CT) and ultrasonography (US) do not improve the overall diagnostic accuracy for acute appendicitis.
DESIGN: Retrospective review.
SETTING: University tertiary care center.
PATIENTS: Seven hundred sixty-six consecutive patients undergoing appendectomy for suspected appendicitis from January 1, 1995, to December 31, 1999.
MAIN OUTCOME MEASURES: Epidemiology of acute appendicitis and the roles of clinical assessment, CT, US, and laparoscopy.
RESULTS: The negative appendectomy rate was 15.7%, and the incidence of perforated appendicitis was 14.6%. A history of migratory pain had the highest positive predictive value (91%), followed by leukocytosis greater than 12 x 10(9)/L (90.1%), CT (83.8%), and US (81.3%). The false-negative rates were 60% for CT and 76.1% for US. Emergency department evaluation took a mean +/- SD of 5.2 +/- 5.4 hours and was prolonged by US or CT (6.4 +/- 7.4 h and 7.8 +/- 10.8 h, respectively). The duration of emergency department evaluation did not affect the perforation rate, but patients with postoperative complications had longer evaluations (mean +/- SD, 8.0 +/- 12.7 h) than did those without (4.8 +/- 3.3 h) (P =.04). Morbidity was 9.1%, 6.4% for nonperforated cases and 19.8% for perforated cases. Seventy-six patients had laparoscopic appendectomy, with a negative appendectomy rate of 42.1%, compared with 15.4% for open appendectomy (P<.001). Laparoscopy, however, had minimal morbidity (1.3%) and correctly identified the abnormality in 91.6% of patients who had a normal-appearing appendix.
CONCLUSIONS: Migratory pain, physical examination, and initial leukocytosis remain reliable and accurate in diagnosing acute appendicitis. Neither CT nor US improves the diagnostic accuracy or the negative appendectomy rate; in fact, they may delay surgical consultation and appendectomy. In atypical cases, one should consider the selective use of diagnostic laparoscopy instead.

PMID 11343547  Arch Surg. 2001 May;136(5):556-62.
著者: John J Hong, Stephen M Cohn, A Peter Ekeh, Martin Newman, Moises Salama, Suzanne D Leblang, Miami Appendicitis Group
雑誌名: Surg Infect (Larchmt). 2003 Fall;4(3):231-9. doi: 10.1089/109629603322419562.
Abstract/Text BACKGROUND: The objective of this study was to determine if routine use of computed tomography (CT) for the diagnosis of appendicitis is warranted.
METHODS: During a one-year study period, all patients who presented to the surgical service with possible appendicitis were studied. One hundred eighty-two patients with possible appendicitis were randomized to clinical assessment (CA) alone, or clinical evaluation and abdominal/pelvic CT. A true-positive case resulted in a laparotomy that revealed a lesion requiring operation. A true-negative case did not require operation at one-week follow-up evaluation. Hospital length of stay, hospital charges, perforation rates, and times to operation were recorded.
RESULTS: The age and gender distributions were similar in both groups. Accuracy was 90% in the CA group and 92% for CT. Sensitivity was 100% for the CA group and 91% for the CT group. Specificity was 73% for CA and 93% for CT. There were no statistically significant differences in hospital length of stay (CA = 2.4 +/- 3.2 days vs. CT = 2.2 +/- 2.2 days, p = 0.55), hospital charges (CA = 10,728 US dollars +/- 10,608 vs. CT = 10,317 US dollars +/- 7,173, p = 0.73) or perforation rates (CA = 6% vs. CT = 9%, p = 0.4). Time to the operating room was shorter in the CA group, 10.6 +/- 8.4 h vs. CT, 19.0 +/- 19.0 h (p < 0.01).
CONCLUSIONS: Clinical assessment unaided by CT reliably identifies patients who need operation for acute appendicitis, and they undergo surgery sooner. Routine use of abdominal/pelvic CT is not warranted. Further research is needed to identify sub-groups of patients who may benefit from CT. Computed tomography should not be considered the standard of care for the diagnosis of appendicitis.

PMID 14588157  Surg Infect (Larchmt). 2003 Fall;4(3):231-9. doi: 10.10・・・
著者: Jong Seob Park, Jin Ho Jeong, Jong In Lee, Jong Hoon Lee, Jea Kun Park, Hyoun Jong Moon
雑誌名: Am Surg. 2013 Jan;79(1):101-6.
Abstract/Text The objectives were to evaluate the effectiveness of ultrasonography, computed tomography, and physical examination for diagnosing acute appendicitis with analyzing their accuracies and negative appendectomy rates in a clinical rather than research setting. A total of 2763 subjects were enrolled. Sensitivity, specificity, positive predictive value, and negative predictive value and negative appendectomy rate for ultrasonography, computed tomography, and physical examination were calculated. Confirmed positive acute appendicitis was defined based on pathologic findings, and confirmed negative acute appendicitis was defined by pathologic findings as well as on clinical follow-up. Sensitivity, specificity, positive predictive value, and negative predictive value for ultrasonography were 99.1, 91.7, 96.5, and 97.7 per cent, respectively; for computed tomography, 96.4, 95.4, 95.6, and 96.3 per cent, respectively; and for physical examination, 99.0, 76.1, 88.1, and 97.6 per cent, respectively. The negative appendectomy rate was 5.8 per cent (5.2% in the ultrasonography group, 4.3% in the computed tomography group, and 12.2% in the physical examination group). Ultrasonography/computed tomography should be performed routinely for diagnosis of acute appendicitis. However, in view of its advantages, ultrasonography should be performed first. Also, if the result of a physical examination is negative, imaging studies after physical examination can be unnecessary.

PMID 23317620  Am Surg. 2013 Jan;79(1):101-6.
著者: Katherine T Morris, Maihgan Kavanagh, Paul Hansen, Mark H Whiteford, Karen Deveney, Blayne Standage
雑誌名: Am J Surg. 2002 May;183(5):547-50.
Abstract/Text BACKGROUND: Recently, limited abdominal computed tomography (CT) scans have been reported (Rao, New England Journal of Medicine, 1998) to have accuracy as high as 98%. We compare our hospital's CT accuracy ordered by emergency room (ER) physicians with that of experienced surgeons provided only with the ER history and physical examination in the evaluation of appendicitis.
METHODS: All charts of patients 16 years or older with limited CT scans ordered by ER from January 1, 1996, through February 28, 1998, were reviewed. CT scans ordered when appendicitis was not in the differential were excluded from analysis. Pathology and clinical follow-up were criterion standards. Four surgeons reviewed ER history and physical and placed them into one of three categories: appendectomy, observe to rule out appendicitis, or discharge with follow-up (included admitting to another service or treating for another disorder).
RESULTS: A total of 526 charts were reviewed; 129 met the criteria for the study. The accuracy of CT scans as used by our ER was not as high as reported in the literature. In addition, surgeon accuracy approached that of the CT scan even without the ability to evaluate the patients in person. Noncontrast CTs were ordered before surgical evaluation in contrast to the Rao protocol, likely reducing their accuracy.
CONCLUSIONS: Ordering CT scans to evaluate for appendicitis prior to surgical evaluation is of limited value.

PMID 12034390  Am J Surg. 2002 May;183(5):547-50.
著者: W Duqoum
雑誌名: East Mediterr Health J. 2001 Jul-Sep;7(4-5):642-5.
Abstract/Text The clinical files of 16,443 women delivered during the period June 1994 to June 2000 at Queen Alia Military Hospital were retrospectively studied for clinical presentation, investigation, operative findings and histopathological diagnosis of appendicitis during pregnancy. The result showed that 10 of the women underwent laparotomy for probable appendicitis. Of these, 8 had positive histopathological diagnosis. Appendicitis in pregnancy occurs infrequently. The clinical presentation varies and diagnosis is usually delayed. Right-side abdominal pain is the principal basis for diagnosis, while leukocytosis and low-level fever, as in the non-pregnant state, are unreliable for diagnosis.

PMID 15332760  East Mediterr Health J. 2001 Jul-Sep;7(4-5):642-5.
著者: R E Andersson, M Lambe
雑誌名: Int J Epidemiol. 2001 Dec;30(6):1281-5.
Abstract/Text BACKGROUND: The aetiology and pathogenesis of appendicitis remains unknown. A relation with female sex hormones has been proposed because of a lower incidence among women and incidence variations during the menstrual cycle, but studies have given inconsistent results. Pregnancy constitutes a period of dramatic increases in levels of female sex hormones, but the incidence of appendicitis during childbearing is not known.
METHODS: Case-control study of pregnancy status at the time of appendectomy of 53 058 women and of 53 058 population-based age-matched controls. Cases and controls were identified by linkage of the Swedish Inpatient Register and the nation-wide census. Pregnancy status at the time of operation was obtained by linkage with the Swedish Fertility Register. Differences in pregnancy status were analysed using conditional logistic regression and expressed as odds ratios (OR) with 95% CI.
RESULTS: Fewer patients than expected with appendicitis were pregnant compared with the controls, especially in the third trimester (OR = 0.49, 95% CI : 0.30-0.79 for perforated and OR = 0.33, 95% CI : 0.28-0.39 for non-perforated appendicitis).
CONCLUSIONS: The reduced incidence of appendicitis suggests a protective effect of pregnancy, especially in the third trimester.

PMID 11821329  Int J Epidemiol. 2001 Dec;30(6):1281-5.
著者: L Daehlin
雑誌名: Acta Chir Scand. 1982;148(3):291-4.
Abstract/Text 49 children younger than 3 years old and treated for acute appendicitis were investigated retrospectively. The symptoms of this age group are general and diarrhea is not uncommon. Examination of the urine including microscopy should always be performed. The white cell count in peripheral blood is of doubtful value in diagnosing acute appendicitis. A roentgenographic examination of the abdomen was helpful in 78% of the patients studied. The correct diagnosis was delayed in 43% of the cases and this extended the observation time by 2.9 +/- 2.4 days. The appendix was perforated in 79%, complications occurred in 18% and there was no mortality. A high degree of alertness seems essential for the early diagnosis of acute appendicitis in this age group.

PMID 7136432  Acta Chir Scand. 1982;148(3):291-4.
著者: M C Horattas, D P Guyton, D Wu
雑誌名: Am J Surg. 1990 Sep;160(3):291-3.
Abstract/Text Historically, appendicitis in the elderly is associated with higher morbidity and mortality. Ninety-six patients over 60 years of age with appendicitis treated over a 10-year period were reviewed. Only 20% presented classically with anorexia, fever, right lower quadrant pain, and an elevated white blood cell count. One third of the patients had greater than 48 hours delay to admission. Objective diagnostic testing was often confusing and unreliable. At the time of admission, only 51% were diagnosed as having possible appendicitis. Eighty-three percent of our patients underwent surgery within 24 hours, and 72% had frank perforation. Thirty-two percent of those surviving developed complications, and 83% of these patients had perforated appendicitis. Complications were twice as likely in patients with perforation. Despite the relatively high morbidity, there were only four deaths in patients with coexistent carcinoma. Because of the later and atypical presentation of appendicitis in this age group, a high index of suspicion and early operation are important in avoiding perforation and subsequent morbidity.

PMID 2393058  Am J Surg. 1990 Sep;160(3):291-3.
著者: C L Temple, S A Huchcroft, W J Temple
雑誌名: Ann Surg. 1995 Mar;221(3):278-81.
Abstract/Text OBJECTIVE: The authors relate prehospital delay and in-hospital delay to the incidence of perforation of appendicitis.
SUMMARY BACKGROUND DATA: Quality assurance studies use perforation rate as an index of quality of care. This is based on the assumption commonly presented in retrospective reports that in-hospital delay to surgery influences the incidence of perforation. Only one limited study prospectively found that prehospital delay increased the perforation rate.
METHODS: During a 6-month period, 95 consecutive adults undergoing appendectomies at Foothills Hospital in Calgary, Alberta, were questioned as to onset and type of first symptom (i.e., epigastric discomfort, anorexia nervosa, vomiting, and abdominal pain). Time of emergency room (ER) arrival, surgery consultation, and operating room start were taken from the chart. Surgical and pathology reports were used to identify status of appendix (normal, inflamed, suppurative, gangrenous, perforated) and presence of abscess cavity. The status of appendix was related to prehospital and in-hospital delay to establish significance.
RESULTS: There were 13 (14%) normal, 67 (70%) inflamed, and 15 (16%) perforated appendices. Patients with perforated appendices waited 2.5 times longer before reporting to the ER, compared with patients with inflamed appendices (57 hours vs. 22 hours, p < 0.007). Once in the hospital, patients with perforated appendices were identified and treated faster than those with inflamed appendices (7 vs. 9 hours, p < 0.039). Analysis by ER physician was 3 hours whether the appendix was normal, inflamed, or perforated. Analysis by the surgeon was significantly shorter in patients with perforated appendices than patients with inflamed appendices (4 vs. 6 hours, p < 0.039).
CONCLUSIONS: This prospective study identifies that delay in presentation accounts for the majority of perforated appendices. Clinical evaluation is effective for identifying patients with more advanced disease. Indiscriminate appendectomy as an attempt to decrease perforation is not supported by these data. Hospital perforation rates likely reflect patient factors, illness attitude, and access to medical care.

PMID 7717781  Ann Surg. 1995 Mar;221(3):278-81.
著者: Ingrid M H A Wilms, Dominique E N M de Hoog, Dianne C de Visser, Heinrich M J Janzing
雑誌名: Cochrane Database Syst Rev. 2011 Nov 9;(11):CD008359. doi: 10.1002/14651858.CD008359.pub2. Epub 2011 Nov 9.
Abstract/Text BACKGROUND: Acute appendicitis is one of the most common causes of acute abdominal pain. Present day treatment of choice for acute appendicitis is appendectomy, however complications are inherent to operative treatment. Though surgical appendectomy remains the standard treatment, several investigators have investigated conservative antibiotic treatment of acute appendicitis and reported good results.
OBJECTIVES: Is antibiotic treatment as effective as surgical appendectomy (laparoscopic or open) in patients with acute appendicitis on recovery within two weeks, without major complications (including recurrence) within one year?
SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 6, 2011); MEDLINE (until June 2011); EMBASE (until June 2011); Prospective Trial Registers (June 2011) and reference lists of articles.
SELECTION CRITERIA: Randomised and quasi-randomised clinical trials (RCT and qRCT) comparing antibiotic treatment with appendectomy in patients with suspected appendicitis were included. Excluded were studies which primarily focused on the complications of acute appendicitis.
DATA COLLECTION AND ANALYSIS: Two authors independently assessed trial quality and extracted data. The review authors contacted the trial authors for additional information if required. Statistical analysis was carried out using Review Manager and MetaAnalyst. A non-inferiority analysis was performed, comparing antibiotic treatment (ABT) to the gold standard (appendectomy). By consensus, a 20% margin of non-inferiority was considered clinically relevant.
MAIN RESULTS: Five RCT's (901 patients) were assessed. In total 73.4% (95% CI 62.7 to 81.9) of patients who were treated with antibiotics and 97.4 (95% CI 94.4 to 98.8) patients who directly got an appendectomy were cured within two weeks without major complications (including recurrence) within one year. The lower 95% CI was 15.2% below the 20% margin for the primary outcome.
AUTHORS' CONCLUSIONS: The upper bound of the 95% CI of ABT for cure within two weeks without major complications crosses the 20% margin of appendectomy, so the outcome is inconclusive. Also the quality of the studies was low to moderate, for that reason the results should be interpret with caution and definite conclusions cannot be made. Therefore we conclude that appendectomy remains the standard treatment for acute appendicitis. Antibiotic treatment might be used as an alternative treatment in a good quality RCT or in specific patients or conditions were surgery is contraindicated.

PMID 22071846  Cochrane Database Syst Rev. 2011 Nov 9;(11):CD008359. d・・・
著者: Krishna K Varadhan, Keith R Neal, Dileep N Lobo
雑誌名: BMJ. 2012 Apr 5;344:e2156. Epub 2012 Apr 5.
Abstract/Text OBJECTIVE: To compare the safety and efficacy of antibiotic treatment versus appendicectomy for the primary treatment of uncomplicated acute appendicitis.
DESIGN: Meta-analysis of randomised controlled trials.
POPULATION: Randomised controlled trials of adult patients presenting with uncomplicated acute appendicitis, diagnosed by haematological and radiological investigations.
INTERVENTIONS: Antibiotic treatment versus appendicectomy.
OUTCOME MEASURES: The primary outcome measure was complications. The secondary outcome measures were efficacy of treatment, length of stay, and incidence of complicated appendicitis and readmissions.
RESULTS: Four randomised controlled trials with a total of 900 patients (470 antibiotic treatment, 430 appendicectomy) met the inclusion criteria. Antibiotic treatment was associated with a 63% (277/438) success rate at one year. Meta-analysis of complications showed a relative risk reduction of 31% for antibiotic treatment compared with appendicectomy (risk ratio (Mantel-Haenszel, fixed) 0.69 (95% confidence interval 0.54 to 0.89); I(2)=0%; P=0.004). A secondary analysis, excluding the study with crossover of patients between the two interventions after randomisation, showed a significant relative risk reduction of 39% for antibiotic therapy (risk ratio 0.61 (0.40 to 0.92); I(2)=0%; P=0.02). Of the 65 (20%) patients who had appendicectomy after readmission, nine had perforated appendicitis and four had gangrenous appendicitis. No significant differences were seen for treatment efficacy, length of stay, or risk of developing complicated appendicitis.
CONCLUSION: Antibiotics are both effective and safe as primary treatment for patients with uncomplicated acute appendicitis. Initial antibiotic treatment merits consideration as a primary treatment option for early uncomplicated appendicitis.

PMID 22491789  BMJ. 2012 Apr 5;344:e2156. Epub 2012 Apr 5.
著者:
雑誌名: Prescrire Int. 2014 Jun;23(150):158-60.
Abstract/Text Appendectomy is the standard treatment for acute appendicitis. Since the 1990s, antibiotic therapy has sometimes been proposed as an alternative to immediate appendectomy. How effective are antibiotics in adults with uncomplicated acute appendicitis, and what is the risk of complications? To answer these questions, we conducted a review of the literature using the standard Prescrire methodology. A systematic review with meta-analysis included four randomised trials of antibiotics versus immediate appendectomy, in 900 patients hospitalised with uncomplicated appendicitis. The studies included only patients with few severe symptoms, thus undermining the strength of the results. Antibiotic therapy was usually administered intravenously first, then orally. The antibiotics used were amoxicillin + clavulanic acid, cefotaxime, or a fluoroquinolone. Metronidazole or tinidazole was often added. The total duration of antibiotic treatment was 8 to 15 days. The overall incidence of complications of appendicitis (perforation, peritonitis and surgical wound infections) was 25% in the immediate appendectomy group versus 18% in the antibiotic group. The frequency of perforations and peritonitis did not differ between the groups. All symptoms of appendicitis disappeared, without relapse or rehospitalisation during the first month, in 78% of patients in the antibiotic group. After one year of follow-up, 63% of patients treated with antibiotics were asymptomatic and had no complications or recurrences. In another systematic review of five randomised trials, outcome at one year was optimal in 73% of patients treated with antibiotics alone versus 97% of patients who had immediate appendectomy. In practice, in early 2014, appendectomy remains the first-line treatment for uncomplicated acute appendicitis. In some still poorly characterised patients, the harm-benefit balance of antibiotic therapy is probably better than that of immediate appendectomy. When informed of the risks, some patients are likely to choose antibiotic therapy.

PMID 25121154  Prescrire Int. 2014 Jun;23(150):158-60.
著者: Johan Styrud, Staffan Eriksson, Ingemar Nilsson, Gunnar Ahlberg, Staffan Haapaniemi, Gunnar Neovius, Lars Rex, Ibrahim Badume, Lars Granström
雑誌名: World J Surg. 2006 Jun;30(6):1033-7. doi: 10.1007/s00268-005-0304-6.
Abstract/Text BACKGROUND: Appendectomy has been the treatment for acute appendicitis for over 120 years. Antibiotic treatment has occasionally been used in small uncontrolled studies, instead of operation, but this alternative has never before been tried in a multicenter randomized trial.
PATIENTS AND METHODS: Male patients, 18-50 years of age, admitted to six different hospitals in Sweden between 1996 and 1999 were enrolled in the study. No women were enrolled by decision of the local ethics committee. If appendectomy was planned, patients were asked to participate, and those who agreed were randomized either to surgery or to antibiotic therapy. Patients randomized to surgery were operated on with open surgery or laparoscopically. Those randomized to antibiotic therapy were treated intravenously for 2 days, followed by oral treatment for 10 days. If symptoms did not resolve within 24 hours, an appendectomy was performed. Participants were monitored at the end of 1 week, 6 weeks, and 1 year.
RESULTS: During the study period 252 men participated, 124 in the surgery group and 128 in the antibiotic group. The frequency of appendicitis was 97% in the surgery group and 5% had a perforated appendix. The complication rate was 14% in the surgery group. In the antibiotic group 86% improved without surgery; 18 patients were operated on within 24 hours, and the diagnosis of acute appendicitis was confirmed in all but one patient, and he was suffering from terminal ileitis. There were seven patients (5%) with a perforated appendix in this group. The rate of recurrence of symptoms of appendicitis among the 111 patients treated with antibiotics was 14% during the 1-year follow-up.
CONCLUSIONS: Acute non-perforated appendicitis can be treated successfully with antibiotics. However, there is a risk of recurrence in cases of acute appendicitis, and this risk should be compared with the risk of complications after appendectomy.

PMID 16736333  World J Surg. 2006 Jun;30(6):1033-7. doi: 10.1007/s0026・・・
著者: Corinne Vons, Caroline Barry, Sophie Maitre, Karine Pautrat, Mahaut Leconte, Bruno Costaglioli, Mehdi Karoui, Arnaud Alves, Bertrand Dousset, Patrice Valleur, Bruno Falissard, Dominique Franco
雑誌名: Lancet. 2011 May 7;377(9777):1573-9. doi: 10.1016/S0140-6736(11)60410-8.
Abstract/Text BACKGROUND: Researchers have suggested that antibiotics could cure acute appendicitis. We assessed the efficacy of amoxicillin plus clavulanic acid by comparison with emergency appendicectomy for treatment of patients with uncomplicated acute appendicitis.
METHODS: In this open-label, non-inferiority, randomised trial, adult patients (aged 18-68 years) with uncomplicated acute appendicitis, as assessed by CT scan, were enrolled at six university hospitals in France. A computer-generated randomisation sequence was used to allocate patients randomly in a 1:1 ratio to receive amoxicillin plus clavulanic acid (3 g per day) for 8-15 days or emergency appendicectomy. The primary endpoint was occurrence of postintervention peritonitis within 30 days of treatment initiation. Non-inferiority was shown if the upper limit of the two-sided 95% CI for the difference in rates was lower than 10 percentage points. Both intention-to-treat and per-protocol analyses were done. This trial is registered with ClinicalTrials.gov, number NCT00135603.
FINDINGS: Of 243 patients randomised, 123 were allocated to the antibiotic group and 120 to the appendicectomy group. Four were excluded from analysis because of early dropout before receiving the intervention, leaving 239 (antibiotic group, 120; appendicectomy group, 119) patients for intention-to-treat analysis. 30-day postintervention peritonitis was significantly more frequent in the antibiotic group (8%, n=9) than in the appendicectomy group (2%, n=2; treatment difference 5·8; 95% CI 0·3-12·1). In the appendicectomy group, despite CT-scan assessment, 21 (18%) of 119 patients were unexpectedly identified at surgery to have complicated appendicitis with peritonitis. In the antibiotic group, 14 (12% [7·1-18·6]) of 120 underwent an appendicectomy during the first 30 days and 30 (29% [21·4-38·9]) of 102 underwent appendicectomy between 1 month and 1 year, 26 of whom had acute appendicitis (recurrence rate 26%; 18·0-34·7).
INTERPRETATION: Amoxicillin plus clavulanic acid was not non-inferior to emergency appendicectomy for treatment of acute appendicitis. Identification of predictive markers on CT scans might enable improved targeting of antibiotic treatment.
FUNDING: French Ministry of Health, Programme Hospitalier de Recherche Clinique 2002.

Copyright © 2011 Elsevier Ltd. All rights reserved.
PMID 21550483  Lancet. 2011 May 7;377(9777):1573-9. doi: 10.1016/S0140・・・
著者: Geoffrey C Garst, Ernest E Moore, Monisha N Banerjee, David K Leopold, Clay Cothren Burlew, Denis D Bensard, Walter L Biffl, Carlton C Barnett, Jeffrey L Johnson, Angela Sauaia
雑誌名: J Trauma Acute Care Surg. 2013 Jan;74(1):32-6. doi: 10.1097/TA.0b013e318278934a.
Abstract/Text BACKGROUND: Analogous to organ injury scales developed for trauma, a scoring system is needed for acute care surgery. The purpose of this study was to develop a disease severity score (DSS) for acute appendicitis, the most common surgical emergency.
METHODS: A panel of acute care surgery experts reviewed the literature and developed a DSS for acute appendicitis as follows: grade 1, inflamed; Grade 2, gangrenous; Grade 3, perforated with localized free fluid; Grade 4, perforated with a regional abscess; and Grade 5, perforated with diffuse peritonitis. We applied the DSS to 1,000 consecutive patients undergoing appendectomy from 1999 to 2009 and examined its association with outcomes (mortality, length of hospital stay, incidence of in-hospital, and postdischarge complications). Of the 1,000 patients, 82 were excluded owing to negative or interval appendectomy or advanced end-stage renal disease.
RESULTS: Among 918 eligible patients, the DSS distribution was Grade 1 at 62.4%, Grade 2 at 13.0%, Grade 3 at 18.7%, Grade 4 at 4.4%, and Grade 5 at 1.5%. Statistical analyses indicated a stepwise risk increase in adverse outcomes with higher DSS grades (c statistics ≥ 0.75 for all outcomes). Covariates (age, sex, and type of surgical access) did not add to the predictive power of DSS.
CONCLUSION: Based on this single-institution study, the proposed appendicitis DSS seems to be a useful tool. This DSS can inform future, national efforts, which can build on the knowledge provided by the present investigation. This DSS may be useful for comparing therapeutic modalities, planning resource use, improving programs, and adjusting reimbursement
LEVEL OF EVIDENCE: Epidemiologic study, level III.

PMID 23271074  J Trauma Acute Care Surg. 2013 Jan;74(1):32-6. doi: 10.・・・
著者: B R Andersen, F L Kallehave, H K Andersen
雑誌名: Cochrane Database Syst Rev. 2005 Jul 20;(3):CD001439. doi: 10.1002/14651858.CD001439.pub2. Epub 2005 Jul 20.
Abstract/Text BACKGROUND: Appendicitis is the most common cause of acute abdominal pain requiring surgical intervention. The cause of appendicitis is unclear and the mechanism of pathogenesis continues to be debated. Despite improved asepsis and surgical techniques, postoperative complications, such as wound infection and intraabdominal abscess, still account for a significant morbidity. Several studies implicate that postoperative infections are reduced by administration of antimicrobial regimes.
OBJECTIVES: This review evaluated the use of antibiotics compared to placebo or no treatment in patients undergoing appendectomy. Will these patients benefit from antimicrobial prophylaxis? The outcomes were described according to the nature of the appendix, as either simple appendicitis (including the non-infectious stage) and complicated appendicitis. The efficacy of different antibiotic regimens were not evaluated.
SEARCH STRATEGY: We searched The Cochrane Central Register of Controlled Trials (Cochrane Library 2005 issue 1); Pubmed ; EMBASE; and the Cochrane Colorectal Cancer Group Specialised Register (April 2005). In addition, we manually searched the reference lists of the primary identified trials.
SELECTION CRITERIA: We evaluated Randomised Controlled Trials (RCTs) and Controlled Clinical Trials (CCTs) in which any antibiotic regime were compared to placebo in patients suspected of having appendicitis, and undergoing appendectomy. Both studies on children and adults were reviewed. The outcome measures of the studies were: Wound infection, intra abdominal abscess, length of stay in hospital, and mortality.
DATA COLLECTION AND ANALYSIS: Eligibility and trial quality were assessed, recorded and cross-checked by two reviewers.
MAIN RESULTS: Forty-five studies including 9576 patients were included in this review. The overall result is that the use of antibiotics is superior to placebo for preventing wound infection and intraabdominal abscess, with no apparent difference in the nature of the removed appendix. Studies exclusively on children and studies examining topical application reported results in favour to the above, although the results were not significant.
AUTHORS' CONCLUSIONS: Antibiotic prophylaxis is effective in the prevention of postoperative complications in appendectomised patients, whether the administration is given pre-, peri- or post-operatively, and could be considered for routine in emergency appendectomies.

PMID 16034862  Cochrane Database Syst Rev. 2005 Jul 20;(3):CD001439. d・・・
著者: Steven L Lee, Saleem Islam, Laura D Cassidy, Fizan Abdullah, Marjorie J Arca, 2010 American Pediatric Surgical Association Outcomes and Clinical Trials Committee
雑誌名: J Pediatr Surg. 2010 Nov;45(11):2181-5. doi: 10.1016/j.jpedsurg.2010.06.038.
Abstract/Text OBJECTIVE: The aim of the study was to review evidence-based data regarding the use of antibiotics for the treatment of appendicitis in children.
DATA SOURCE: Data were obtained from PubMed, MEDLINE, and citation review.
STUDY SELECTION: We conducted a literature search using "appendicitis" combined with "antibiotics" with children as the target patient population. Studies were selected based on relevance for the following questions: (1) What perioperative antibiotics should be used for pediatric patients with nonperforated appendicitis? (2) For patients with perforated appendicitis treated with appendectomy: a. What perioperative intravenous antibiotics should be used? b. How long should perioperative intravenous antibiotics be used? c. Should oral antibiotics be used? (3) For patients with perforated appendicitis treated with initial nonoperative management, what antibiotics should be used in the initial management?
RESULTS: Children with nonperforated appendicitis should receive preoperative, broad-spectrum antibiotics. In children with perforated appendicitis who had undergone appendectomy, intravenous antibiotic duration should be based on clinical criteria. Furthermore, broad-spectrum, single, or double agent therapy is as equally efficacious as but is more cost-effective than triple agent therapy. If intravenous antibiotics are administered for less than 5 days, oral antibiotics should be administered for a total antibiotic course of 7 days. For children with perforated appendicitis who did not initially undergo an appendectomy, the duration of broad-spectrum, intravenous antibiotics should be based on clinical symptoms.
CONCLUSIONS: Current evidence supports the use of guidelines as described above for antibiotic therapy in children with acute and perforated appendicitis.

Copyright © 2010 Elsevier Inc. All rights reserved.
PMID 21034941  J Pediatr Surg. 2010 Nov;45(11):2181-5. doi: 10.1016/j.・・・
著者: Joseph S Solomkin, John E Mazuski, John S Bradley, Keith A Rodvold, Ellie J C Goldstein, Ellen J Baron, Patrick J O'Neill, Anthony W Chow, E Patchen Dellinger, Soumitra R Eachempati, Sherwood Gorbach, Mary Hilfiker, Addison K May, Avery B Nathens, Robert G Sawyer, John G Bartlett
雑誌名: Clin Infect Dis. 2010 Jan 15;50(2):133-64. doi: 10.1086/649554.
Abstract/Text Evidence-based guidelines for managing patients with intra-abdominal infection were prepared by an Expert Panel of the Surgical Infection Society and the Infectious Diseases Society of America. These updated guidelines replace those previously published in 2002 and 2003. The guidelines are intended for treating patients who either have these infections or may be at risk for them. New information, based on publications from the period 2003-2008, is incorporated into this guideline document. The panel has also added recommendations for managing intra-abdominal infection in children, particularly where such management differs from that of adults; for appendicitis in patients of all ages; and for necrotizing enterocolitis in neonates.

PMID 20034345  Clin Infect Dis. 2010 Jan 15;50(2):133-64. doi: 10.1086・・・
著者: E Skoubo-Kristensen, I Hvid
雑誌名: Ann Surg. 1982 Nov;196(5):584-7.
Abstract/Text During a ten-year period 193 patients with an appendiceal mass--and subsequently proved postinflammatory changes of the appendix--were treated conservatively. The course was uneventful in 88%. Twelve per cent underwent delayed surgical intervention caused by complications with one death. Elective appendectomy was performed after three months with a complication rate of 3.4%. In comparison with series with early operation the conservative management seems to carry a lower morbidity. The value of elective appendectomy is discussed.

PMID 7125745  Ann Surg. 1982 Nov;196(5):584-7.
著者: S Nitecki, A Assalia, M Schein
雑誌名: Br J Surg. 1993 Jan;80(1):18-20.
Abstract/Text An appendiceal mass is the end result of a walled-off appendiceal perforation and represents a pathological spectrum ranging from phlegmon to abscess. Over the past decade, improved imaging and interventional radiological techniques have allowed a more accurate definition of pathology and thus a more specific and less invasive management than was previously possible. A management policy should be possible that allows over 80 per cent of patients presenting with an appendiceal mass to be safely spared an open operation.

PMID 8428281  Br J Surg. 1993 Jan;80(1):18-20.
著者: D Oliak, D Yamini, V M Udani, R J Lewis, T Arnell, H Vargas, M J Stamos
雑誌名: Dis Colon Rectum. 2001 Jul;44(7):936-41.
Abstract/Text PURPOSE: Our goal was to compare initial operative and nonoperative management for periappendiceal abscess complicating appendicitis.
METHODS: This study is a retrospective review of 155 consecutive patients with appendicitis complicated by periappendiceal abscess treated between 1992 and 1998. Eighty-eight patients were treated initially nonoperatively, and 67 patients were treated operatively. All patients had localized abdominal tenderness and either computed tomography or intraoperative documentation of an abscess.
RESULTS: Our patient population consisted of 107 males and 48 females, with an average age of 33 (range, 16-75) years. Age, gender, comorbidity, white blood cell count, temperature, and heart rate did not differ significantly between groups. For the initial nonoperative management group, the failure rate was 5.8 percent and the appendicitis recurrence rate was 8 percent after a mean follow-up of 36 weeks. The response to treatment of the initial nonoperative group and the initial operative group was compared by length of stay (9 +/- 5 days vs. 9 +/- 3 days; P = not significant), days until white blood cell count normalized (3.8 +/- 4 days vs. 3.1 +/- 3 days; P = not significant), days until temperature normalized (3.2 +/- 3 days vs. 3.1 +/- 2 days; P = not significant), and days until a regular diet was tolerated (4.7 +/- 4 days vs. 4.6 +/- 3 days; P = not significant). Complication rate was significantly lower in the nonoperative group (17 vs. 36 percent; P = 0.008).
CONCLUSIONS: Initial nonoperative management of appendicitis complicated by periappendiceal abscess is safe and effective. Patients undergoing initial nonoperative management have a lower rate of complications, but they are at risk for recurrent appendicitis.

PMID 11496072  Dis Colon Rectum. 2001 Jul;44(7):936-41.
著者: P Bagi, S Dueholm
雑誌名: Surgery. 1987 May;101(5):602-5.
Abstract/Text Forty patients with an ultrasonically evaluated appendiceal mass were studied. Abscesses were diagnosed in 31 patients (78%). Seventeen patients had an ultrasonically guided percutaneous drainage performed, and all but one patient had resolution of symptoms without further treatment or complications. Fourteen patients were treated conservatively without drainage, and 12 had resolution of symptoms without interference. Ultrasonograms in the remaining nine patients (22%) revealed phlegmonous inflammation only, and all recovered without treatment. The three patients considered failures had surgery because of intestinal obstruction or suspected but unverified perforation. Three patients (8.5%) had recurrent appendicitis within 5 months after the initial attack. Diagnostic errors delayed proper therapy for 1 month in a patient with a cecal carcinoma and for 5 months in a patient with Crohn's disease. Late sequelae were observed in four patients, three of whom had surgery. Nonoperative treatment and if possible ultrasonically guided percutaneous drainage of verified abscesses are safe procedures with few complications and late sequelae. However, diligent in-hospital observation and close follow-up are mandatory.

PMID 3554578  Surgery. 1987 May;101(5):602-5.
著者: B Siewert, V Raptopoulos
雑誌名: AJR Am J Roentgenol. 1994 Dec;163(6):1317-24. doi: 10.2214/ajr.163.6.7992721.
Abstract/Text An acute abdomen is a clinical condition characterized by severe abdominal pain that develops suddenly over several hours or less [1]. Abdominal tenderness and rigidity, either generalized or localized, usually are severe and indicate an urgent need for prompt diagnosis and treatment. The underlying cause of acute abdomen varies, and some cases require immediate surgical treatment, whereas for others, surgery is unnecessary or contraindicated. This need for prompt diagnosis and treatment should not preclude an appropriate investigation to establish the precise diagnosis before undertaking surgery [1, 2].

PMID 7992721  AJR Am J Roentgenol. 1994 Dec;163(6):1317-24. doi: 10.2・・・
著者: Carlos V R Brown, Michael Abrishami, Matthew Muller, George C Velmahos
雑誌名: Am Surg. 2003 Oct;69(10):829-32.
Abstract/Text Conflicting evidence exists regarding the optimal treatment for abscess complicating acute appendicitis. The objective of this study is to compare immediate appendectomy (IMM APP) versus expectant management (EXP MAN) including percutaneous drainage with or without interval appendectomy to treat periappendiceal abscess. One hundred four patients with acute appendicitis complicated by periappendiceal abscess were identified. We compared 36 patients who underwent IMM APP with 68 patients who underwent EXP MAN. Outcome measures included morbidity and length of hospital stay. The groups were similar with regard to age (30.6 +/- 12.3 vs. 34.8 +/- 13.5 years), gender (61% vs. 62% males), admission WBC count (17.5 +/- 5.1 x 10(3) vs. 17.0 +/- 4.8 x 10(3) cells/dL), and admission temperature (37.9 +/- 1.2 vs. 37.8 +/- 0.9 degrees F). IMM APP patients had a higher rate of complications than EXP MAN patients at initial hospitalization (58% vs. 15%, P < 0.001) and for all hospitalizations (67% vs. 24%, P < 0.001). The IMM APP group also had a longer initial (14.8 +/- 16.1 vs. 9.0 +/- 4.8 days, P = 0.01) and overall hospital stay (15.3 +/- 16.2 vs. 10.7 +/- 5.4 days, P = 0.04). We conclude that percutaneous drainage and interval appendectomy is preferable to immediate appendectomy for treatment of appendiceal abscess because it leads to a lower complication rate and a shorter hospital stay.

PMID 14570357  Am Surg. 2003 Oct;69(10):829-32.
著者: Stefan Sauerland, Thomas Jaschinski, Edmund Am Neugebauer
雑誌名: Cochrane Database Syst Rev. 2010 Oct 6;(10):CD001546. doi: 10.1002/14651858.CD001546.pub3. Epub 2010 Oct 6.
Abstract/Text BACKGROUND: Laparoscopic surgery for acute appendicitis has been proposed to have advantages over conventional surgery.
OBJECTIVES: To compare the diagnostic and therapeutic effects of laparoscopic and conventional 'open' surgery.
SEARCH STRATEGY: We searched the Cochrane Library, MEDLINE, EMBASE, LILACS, CNKI, SciSearch, study registries, and the congress proceedings of endoscopic surgical societies.
SELECTION CRITERIA: We included randomized clinical trials comparing laparoscopic (LA) versus open appendectomy (OA) in adults or children. Studies comparing immediate OA versus diagnostic laparoscopy (followed by LA or OA if necessary) were separately identified.
DATA COLLECTION AND ANALYSIS: Two reviewers independently assessed trial quality. Missing information or data was requested from the authors. We used odds ratios (OR), relative risks (RR), and 95% confidence intervals (CI) for analysis.
MAIN RESULTS: We included 67 studies, of which 56 compared LA (with or without diagnostic laparoscopy) vs. OA in adults. Wound infections were less likely after LA than after OA (OR 0.43; CI 0.34 to 0.54), but the incidence of intraabdominal abscesses was increased (OR 1.87; CI 1.19 to 2.93). The duration of surgery was 10 minutes (CI 6 to 15) longer for LA. Pain on day 1 after surgery was reduced after LA by 8 mm (CI 5 to 11 mm) on a 100 mm visual analogue scale. Hospital stay was shortened by 1.1 day (CI 0.7 to 1.5). Return to normal activity, work, and sport occurred earlier after LA than after OA. While the operation costs of LA were significantly higher, the costs outside hospital were reduced. Seven studies on children were included, but the results do not seem to be much different when compared to adults. Diagnostic laparoscopy reduced the risk of a negative appendectomy, but this effect was stronger in fertile women (RR 0.20; CI 0.11 to 0.34) as compared to unselected adults (RR 0.37; CI 0.13 to 1.01).
AUTHORS' CONCLUSIONS: In those clinical settings where surgical expertise and equipment are available and affordable, diagnostic laparoscopy and LA (either in combination or separately) seem to have various advantages over OA. Some of the clinical effects of LA, however, are small and of limited clinical relevance. In spite of the mediocre quality of the available research data, we would generally recommend to use laparoscopy and LA in patients with suspected appendicitis unless laparoscopy itself is contraindicated or not feasible. Especially young female, obese, and employed patients seem to benefit from LA.

PMID 20927725  Cochrane Database Syst Rev. 2010 Oct 6;(10):CD001546. d・・・
著者: M J Greenall, M Evans, A V Pollock
雑誌名: Br J Surg. 1978 Dec;65(12):880-2.
Abstract/Text One hundred and three consecutive patients undergoing appendicectomy for perforated appendicitis were randomly allocated either to have an intraperitoneal drain inserted or not. The results of this trial lend no support to the advocates of drainage.

PMID 737427  Br J Surg. 1978 Dec;65(12):880-2.
著者: Henrik Petrowsky, Nicolas Demartines, Valentin Rousson, Pierre-Alain Clavien
雑誌名: Ann Surg. 2004 Dec;240(6):1074-84; discussion 1084-5.
Abstract/Text OBJECTIVE: To determine the evidence-based value of prophylactic drainage in gastrointestinal (GI) surgery.
METHODS: An electronic search of the Medline database from 1966 to 2004 was performed to identify articles comparing prophylactic drainage with no drainage in GI surgery. The studies were reviewed and classified according to their quality of evidence using the grading system proposed by the Oxford Centre for Evidence-based Medicine. Seventeen randomized controlled trials (RCTs) were found for hepato-pancreatico-biliary surgery, none for upper GI tract, and 13 for lower GI tract surgery. If sufficient RCTs were identified, we performed a meta-analysis to characterize the drain effect using the random-effects model.
RESULTS: There is evidence of level 1a that drains do not reduce complications after hepatic, colonic, or rectal resection with primary anastomosis and appendectomy for any stage of appendicitis. Drains were even harmful after hepatic resection in chronic liver disease and appendectomy. In the absence of RCTs, there is a consensus (evidence level 5) about the necessity of prophylactic drainage after esophageal resection and total gastrectomy due to the potential fatal outcome in case of anastomotic and gastric leakage.
CONCLUSION: Many GI operations can be performed safely without prophylactic drainage. Drains should be omitted after hepatic, colonic, or rectal resection with primary anastomosis and appendectomy for any stage of appendicitis (recommendation grade A), whereas prophylactic drainage remains indicated after esophageal resection and total gastrectomy (recommendation grade D). For many other GI procedures, especially involving the upper GI tract, there is a further demand for well-designed RCTs to clarify the value of prophylactic drainage.

PMID 15570212  Ann Surg. 2004 Dec;240(6):1074-84; discussion 1084-5.
著者: SCOAP Collaborative, Joseph Cuschieri, Michael Florence, David R Flum, Gregory J Jurkovich, Paul Lin, Scott R Steele, Rebecca Gaston Symons, Richard Thirlby
雑誌名: Ann Surg. 2008 Oct;248(4):557-63. doi: 10.1097/SLA.0b013e318187aeca.
Abstract/Text OBJECTIVE: To evaluate negative appendectomy (NA) and the relationship of NA and computed tomography (CT) and/or ultrasound (US). SUMMARY BACKGROUND INFORMATION: NA may be influenced by the use and accuracy of preoperative CT/US. The Surgical Care and Outcomes Assessment Program (SCOAP) gathers chart-abstracted process of care data (such as CT/US accuracy) for general surgical procedures (including appendectomy) at most Washington State hospitals.
METHODS: We determined the prevalence of NA and CT/US concordance at the 15 SCOAP hospitals with >50 consecutive patients undergoing appendectomy (2006-2007).
RESULTS: The number of patients who underwent urgent appendectomies was 3540. The percentage of patients who had imaging (CT-91%) was 86% (women-89%, men-83%). The use of imaging ranged across hospitals from 56% to 97%. There was 91% agreement between imaging and pathology report findings (92.3%-CT and 82.4%-US). The overall rate of NA was 6% (women-8%, men-4%). The prevalence of NA was 9.8% among patients having no imaging, 8.1% among those having an US, and 4.5% in those having a CT. Among patients with NA, CT/US was obtained in 75%; correct in 10% and incorrect or ambiguous in 65%. Higher rates of NA were correlated with lower rates of CT/US concordance (r = -0.57). There was no significant difference in rates of perforation between those with (17%) and without (15%) imaging (P = 0.2). There were significant increases in the use of CT/US and decreases in NA over the time period (P < 0.01).
CONCLUSIONS: The prevalence of NA at SCOAP hospitals decreased significantly. Variation in NA between hospitals was linked closely to CT/US accuracy suggesting CT/US accuracy should be considered a measure of quality in the care of patients with presumed appendicitis.

PMID 18936568  Ann Surg. 2008 Oct;248(4):557-63. doi: 10.1097/SLA.0b01・・・
著者: Sudeshna Sar, Kamal K Mahawar, Ralph Marsh, Peter K Small
雑誌名: Cases J. 2009 Jul 24;2:7776. doi: 10.4076/1757-1626-2-7776. Epub 2009 Jul 24.
Abstract/Text INTRODUCTION: Interval appendicectomy is not routinely indicated after successful resolution of an appendix mass. Whether this policy can also be applied to patients with appendicular foreign body presenting with an appendix mass remains a matter of debate. We report here a patient who presented with recurrent symptoms following conservative management of an appendicular mass associated with a foreign body in the appendix. We also review the available literature briefly.
CASE PRESENTATION: A 70 year old gentleman was admitted with right iliac fossa pain, tenderness, and raised inflammatory markers. A computed tomography scan of his abdomen showed an appendix mass with a small abscess and a linear opaque foreign body. His symptoms resolved completely on conservative management with intravenous antibiotics. A colonoscopy few weeks later was unremarkable. He presented with recurrent symptoms a few months later. A repeat computed tomography scan showed persistent appendicular abscess with the same foreign body in it. A laparotomy with appendicectomy, abscess drainage and removal of the foreign body was carried out with satisfactory outcome.
CONCLUSION: Surgeons should be aware of appendicular foreign body as a cause of persistent/recurrent symptoms after conservative management of appendicular mass. These patients require prompt surgery and formal appendicectomy. Interval appendicectomy should be considered.

PMID 19830011  Cases J. 2009 Jul 24;2:7776. doi: 10.4076/1757-1626-2-7・・・
著者: H A Amoli, A Golozar, S Keshavarzi, H Tavakoli, A Yaghoobi
雑誌名: Emerg Med J. 2008 Sep;25(9):586-9. doi: 10.1136/emj.2007.050914.
Abstract/Text BACKGROUND: The administration of analgesics to patients with acute abdominal pain due to acute appendicitis is controversial. A study was undertaken to assess the analgesic effect of morphine in patients with acute appendicitis.
METHODS: A randomised double-blind clinical trial was conducted in Sina hospital, a general teaching hospital, from January 2004 to March 2005. Patients scheduled for appendectomy were randomised to receive 0.1 mg/kg morphine sulfate or saline (0.9%) to a maximum dose of 10 mg over a 5 min period. Patients were examined by surgeons not involved in their care before and after drug administration and their pain intensity and signs were recorded at each visit. The physicians were also asked to indicate their own treatment plan. The main outcome measures were pain intensity using a visual analogue scale (VAS) and signs of acute appendicitis. A favourable reduction in VAS score was defined as a change of >13 mm.
RESULTS: Of the 71 patients enrolled in the study, 35 were allocated to receive morphine and 36 to receive placebo. One patient left the hospital before receiving morphine. No significant differences were seen between the two groups with regard to age, sex and initial VAS score. A more favourable change in VAS score was reported in the morphine group with a significantly greater reduction in the median VAS score than in the placebo group. Morphine administration did not cause significant changes in patients' signs or in the physicians' plans or diagnoses. No adverse events were seen in either group.
CONCLUSION: Morphine can reduce pain in patients with acute appendicitis without affecting diagnostic accuracy.
TRIAL REGISTRATION NUMBER: NCT00477061.

PMID 18723709  Emerg Med J. 2008 Sep;25(9):586-9. doi: 10.1136/emj.200・・・
著者: Jayson D Aydelotte, Jacob F Collen, R Russell Martin
雑誌名: Curr Surg. 2004 Jul-Aug;61(4):373-5. doi: 10.1016/j.cursur.2004.01.008.
Abstract/Text BACKGROUND: The attitudes of surgeons and nonsurgeons regarding the administration of pain medicine prior to arriving at a surgical diagnosis are changing. It is common practice to administer narcotic analgesics prior to a general surgeon's evaluation. Several studies have advocated the safety of this practice in the emergency department. Many of these studies are flawed by inclusion of many patients who did not have a surgical illness. Our study examined the practice of narcotic administration in patients determined to have appendicitis who underwent operation.
METHODS: We retrospectively reviewed 75 consecutive appendectomies. Emergency department records and in-patient charts were reviewed to assess differences in 2 groups of patients: those who received narcotic pain medicine and those who did not. Specific outcome parameters were reviewed such as time in hospital, time to the operating room, and complication rate. We also created a scoring system for the physical examination to attempt to quantify a difference between the groups.
FINDINGS: Overall, 75 patient charts were reviewed. Nine patients were excluded. There was no statistically significant difference in the 2 groups in regard to time in hospital, time to operation, complication rate, perforation rate, or negative appendectomy rate. The physical examination scoring system did show a difference between those who got pain medicine and those who did not, but failed to show a difference between examiners after pain medicine was given.
CONCLUSIONS: There does not appear to be a difference in hospital stay, time to the operating room, complication rate, negative appendectomy rate, or perforation rate in patients who received pain medicine prior to a surgeon's evaluation and those who did not in this retrospective review.

PMID 15276343  Curr Surg. 2004 Jul-Aug;61(4):373-5. doi: 10.1016/j.cur・・・
著者: Mirjam Busch, Florian S Gutzwiller, Sonja Aellig, Rolf Kuettel, Urs Metzger, Urs Zingg
雑誌名: World J Surg. 2011 Jul;35(7):1626-33. doi: 10.1007/s00268-011-1101-z.
Abstract/Text BACKGROUND: The influence of in-hospital delay (time between admission and operation) on outcome after appendectomy is controversial.
METHODS: A total of 1,827 adult patients underwent open or laparoscopic appendectomy for suspected appendicitis in eleven Swiss hospitals between 2003 and 2006. Of these, 1,675 patients with confirmed appendicitis were included in the study. Groups were defined according in-hospital delay (≤12 vs. >12 h).
RESULTS: Delay>12 h was associated with a significantly higher frequency of perforated appendicitis (29.7 vs. 22.7%; P=0.010) whereas a delay of 6 or 9 h was not. Size of institution, time of admission, and surgical technique (laparoscopic vs. open) were independent factors influencing in-hospital delay. Admission during regular hours was associated with higher age, higher frequency of co-morbidity, and higher perforation rate compared to admission after hours. The logistic regression identified four independent factors associated with an increased perforation rate: age (≤65 years vs. >65 years, odds ratio (OR) 4.5, P<0.001); co-morbidity (Charlson index>0 vs. Charlson index=0, OR 2.3, P<0.001); time of admission (after hours vs. regular hours, OR 0.8, P=0.040), in-hospital delay (>12 vs. ≤12 h, OR 1.5, P=0.005). Perforation was associated with an increased reintervention rate (13.4 vs. 1.6%; P<0.001) and longer length of hospital stay (9.5 vs. 4.4 days; P<0.001).
CONCLUSIONS: In-hospital delay negatively influences outcome after appendectomy. In-hospital delay of more than 12 h, age over 65 years, time of admission during regular hours, and the presence of co-morbidity are all independent risk factors for perforation. Perforation was associated with a higher reintervention rate and increased length of hospital stay.

PMID 21562871  World J Surg. 2011 Jul;35(7):1626-33. doi: 10.1007/s002・・・
著者: Constantinos Simillis, Panayiotis Symeonides, Andrew J Shorthouse, Paris P Tekkis
雑誌名: Surgery. 2010 Jun;147(6):818-29. doi: 10.1016/j.surg.2009.11.013. Epub 2010 Feb 10.
Abstract/Text BACKGROUND: No standardized approach is available for the management of complicated appendicitis defined as appendiceal abscess and phlegmon. This study used meta-analytic techniques to compare conservative treatment versus acute appendectomy.
METHODS: Comparative studies were identified by a literature search. The end points evaluated were overall complications, need for reoperation, duration of hospital stay, and duration of intravenous antibiotics. Heterogeneity was assessed and a sensitivity analysis was performed to account for bias in patient selection.
RESULTS: Seventeen studies (16 nonrandomized retrospective and 1 nonrandomized prospective) reported on 1,572 patients: 847 patients received conservative treatment and 725 had acute appendectomy. Conservative treatment was associated with significantly less overall complications, wound infections, abdominal/pelvic abscesses, ileus/bowel obstructions, and reoperations. No significant difference was found in the duration of first hospitalization, the overall duration of hospital stay, and the duration of intravenous antibiotics. Overall complications remained significantly less in the conservative treatment group during sensitivity analysis of studies including only pediatric patients, high-quality studies, more recent studies, and studies with a larger group of patients.
CONCLUSION: The conservative management of complicated appendicitis is associated with a decrease in complication and reoperation rate compared with acute appendectomy, and it has a similar duration of hospital stay. Because of significant heterogeneity between studies, additional studies should be undertaken to confirm these findings.

Copyright 2010. Published by Mosby, Inc.
PMID 20149402  Surgery. 2010 Jun;147(6):818-29. doi: 10.1016/j.surg.20・・・
著者: Paulina Salminen, Hannu Paajanen, Tero Rautio, Pia Nordström, Markku Aarnio, Tuomo Rantanen, Risto Tuominen, Saija Hurme, Johanna Virtanen, Jukka-Pekka Mecklin, Juhani Sand, Airi Jartti, Irina Rinta-Kiikka, Juha M Grönroos
雑誌名: JAMA. 2015 Jun 16;313(23):2340-8. doi: 10.1001/jama.2015.6154.
Abstract/Text IMPORTANCE: An increasing amount of evidence supports the use of antibiotics instead of surgery for treating patients with uncomplicated acute appendicitis.
OBJECTIVE: To compare antibiotic therapy with appendectomy in the treatment of uncomplicated acute appendicitis confirmed by computed tomography (CT).
DESIGN, SETTING, AND PARTICIPANTS: The Appendicitis Acuta (APPAC) multicenter, open-label, noninferiority randomized clinical trial was conducted from November 2009 until June 2012 in Finland. The trial enrolled 530 patients aged 18 to 60 years with uncomplicated acute appendicitis confirmed by a CT scan. Patients were randomly assigned to early appendectomy or antibiotic treatment with a 1-year follow-up period.
INTERVENTIONS: Patients randomized to antibiotic therapy received intravenous ertapenem (1 g/d) for 3 days followed by 7 days of oral levofloxacin (500 mg once daily) and metronidazole (500 mg 3 times per day). Patients randomized to the surgical treatment group were assigned to undergo standard open appendectomy.
MAIN OUTCOMES AND MEASURES: The primary end point for the surgical intervention was the successful completion of an appendectomy. The primary end point for antibiotic-treated patients was discharge from the hospital without the need for surgery and no recurrent appendicitis during a 1-year follow-up period.
RESULTS: There were 273 patients in the surgical group and 257 in the antibiotic group. Of 273 patients in the surgical group, all but 1 underwent successful appendectomy, resulting in a success rate of 99.6% (95% CI, 98.0% to 100.0%). In the antibiotic group, 70 patients (27.3%; 95% CI, 22.0% to 33.2%) underwent appendectomy within 1 year of initial presentation for appendicitis. Of the 256 patients available for follow-up in the antibiotic group, 186 (72.7%; 95% CI, 66.8% to 78.0%) did not require surgery. The intention-to-treat analysis yielded a difference in treatment efficacy between groups of -27.0% (95% CI, -31.6% to ∞) (P = .89). Given the prespecified noninferiority margin of 24%, we were unable to demonstrate noninferiority of antibiotic treatment relative to surgery. Of the 70 patients randomized to antibiotic treatment who subsequently underwent appendectomy, 58 (82.9%; 95% CI, 72.0% to 90.8%) had uncomplicated appendicitis, 7 (10.0%; 95% CI, 4.1% to 19.5%) had complicated acute appendicitis, and 5 (7.1%; 95% CI, 2.4% to 15.9%) did not have appendicitis but received appendectomy for suspected recurrence. There were no intra-abdominal abscesses or other major complications associated with delayed appendectomy in patients randomized to antibiotic treatment.
CONCLUSIONS AND RELEVANCE: Among patients with CT-proven, uncomplicated appendicitis, antibiotic treatment did not meet the prespecified criterion for noninferiority compared with appendectomy. Most patients randomized to antibiotic treatment for uncomplicated appendicitis did not require appendectomy during the 1-year follow-up period, and those who required appendectomy did not experience significant complications.
TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01022567.

PMID 26080338  JAMA. 2015 Jun 16;313(23):2340-8. doi: 10.1001/jama.201・・・
著者: Julian C Harnoss, Isabelle Zelienka, Pascal Probst, Kathrin Grummich, Catharina Müller-Lantzsch, Jonathan M Harnoss, Alexis Ulrich, Markus W Büchler, Markus K Diener
雑誌名: Ann Surg. 2017 May;265(5):889-900. doi: 10.1097/SLA.0000000000002039.
Abstract/Text OBJECTIVE: The aim was to investigate available evidence regarding effectiveness and safety of surgical versus conservative treatment of acute appendicitis.
SUMMARY OF BACKGROUND DATA: There is ongoing debate on the merits of surgical and conservative treatment for acute appendicitis.
METHODS: A systematic literature search (Cochrane Library, Medline, Embase) and hand search of retrieved reference lists up to January 2016 was conducted to identify randomized and nonrandomized studies. After critical appraisal, data were analyzed using a random-effects model in a Mantel-Haenszel test or inverse variance to calculate risk ratio (RR) or mean difference (MD) with 95% confidence intervals (CIs).
RESULTS: Four trials and four cohort studies (2551 patients) were included. We found that 26.5% of patients in the conservative group needed appendectomy within 1 year, resulting in treatment effectiveness of 72.6%, significantly lower than the 99.4% in the surgical group, (RR 0.75; 95% CI 0.7-0.79; P = 0.00001; I = 62%). Overall postoperative complications were comparable (RR 0.95; 95% CI 0.35-2.58; P = 0.91; I = 0%), whereas the rate of adverse events (RR 3.18; 95% CI 1.63-6.21; P = 0.0007; I = 1%) and the incidence of complicated appendicitis (RR 2.52; 95% CI 1.17-5.43; P = 0.02; I = 0%) were significantly higher in the antibiotic treatment group. Randomized trials showed significantly longer hospital stay in the antibiotic treatment group (RR 0.3 days; 95% CI 0.07-0.53; P = 0.009; I = 49%).
CONCLUSIONS: Although antibiotics may prevent some patients from appendectomies, surgery represents the definitive, one-time only treatment with a well-known risk profile, whereas the long-term impact of antibiotic treatment on patient quality of life and health care costs is unknown. This systematic review and meta-analysis helps physicians and patients in choosing between treatment options depending on whether they are risk averse or risk takers.

PMID 27759621  Ann Surg. 2017 May;265(5):889-900. doi: 10.1097/SLA.000・・・
著者: T Mussack, S Schmidbauer, A Nerlich, W Schmidt, K K Hallfeldt
雑誌名: Chirurg. 2002 Jul;73(7):710-5.
Abstract/Text INTRODUCTION: Chronic appendicitis is not generally accepted as an independent clinical entity. The diagnosis is often made only after histological analysis when the patient has undergone appendectomy in a case of persistent or recurrent pain. The objectives of this prospective study were to analyse the incidence of chronic appendicitis among our patients, to compare demographic and clinical data with histological results and to evaluate long-term follow-up after appendectomy.
METHODS: Between November 1995 and February 1998, 322 patients underwent appendectomy due to typical symptoms of appendicitis. All appendices were analysed macroscopically by the surgeon and histologically by two independent pathologists. Furthermore, demographic data, standard blood results, Alvarado score, body mass index, operation time, complications, and length of hospital stay were evaluated. In April 2001, a long-term follow-up survey evaluated the present complaints of all operated patients.
RESULTS: A total of 112 patients showed clinical signs of non-acute appendicitis. However, 26.8% of these appendices histologically revealed an acute inflammation. In the subgroup of histologically non-acute appendicitis, 4.9% of the appendices were inconspicuous, 42.0% chronically inflamed and 50.6% fibrotic. Compared to that, the macroscopic examination by the surgeon resulted in a 93.5% specificity and a 77.8% sensitivity. The preoperative period of pain was significantly longer (7 days) compared to patients with acute appendicitis (0.5 days). White blood count (8.700 versus 13.400) and preoperative Alvarado score (4 versus 7 points) were significantly lower, the hospital stay significantly shorter (3 versus 4 days). A specificity of 89.9% and a positive likelihood ratio of 4.64 were calculated for an optimal cut-off value of 7 days for preoperative pain. At a median of 50.2 months after the operation, 93.1% of the patients were asymptomatic, and five patients reported persistent pain in the right lower quadrant.
CONCLUSIONS: Three quarter of all patients with pain in the right lower quadrant but no significant signs of inflammation showed the histological criteria for chronic appendicitis. However, histology revealed signs of an acute inflammation in 25% of patients. An optimal cut-off value of 7 days preoperative period of pain was able to suggest a histologically non-acute appendicitis with a high specificity and a high positive predictive value. More than 93% of these patients were asymptomatic in their long-term follow-up. Chronic appendicitis must be assumed in cases of recurrent or persistent pain longer than 7 days and an elective appendectomy has to be recommended.

PMID 12242981  Chirurg. 2002 Jul;73(7):710-5.
著者: S Leardi, S Delmonaco, T Ventura, A Chiominto, G De Rubeis, M Simi
雑誌名: Minerva Chir. 2000 Jan-Feb;55(1-2):39-44.
Abstract/Text BACKGROUND: Chronic appendicitis may be the cause of recurrent abdominal pain. This hypothesis is the subject of controversy. The aim is to clarify the possible existence of a chronic inflammation of the appendix by a clinical and histopathologic study.
METHODS: The case history and the preoperative symptoms and serum findings of 269 patients with appendectomy have been studied. All the appendices have been histologically examined. Chronic appendicitis was diagnosed when at least two typical histological factors of chronic inflammation were present. The histological findings of the appendices have been correlated with preoperative clinical and serum findings of the patients. 14-46 months after the appendectomy, the patients have been examined.
RESULTS: Histological examination revealed 187 cases (69.5%) with acute appendicitis, 44 cases (16.3%) with non disease of appendix and 38 cases (14.2%) with chronic appendicitis. Recurrent abdominal pain and normal leukocyte count were closely correlated (chi 2 = 18.3, p < 0.001; chi 2 = 21.3, p < 0.001 respectively) with diagnosis of chronic appendicitis. 81.8% of 33 patients with chronic appendicitis who underwent follow-up had relief of all the symptoms after appendectomy.
CONCLUSION: Therefore, the study seems to confirm the existence of a clinico-pathological condition that can be defined as chronic appendicitis, resolvable with appendectomy.

PMID 10832282  Minerva Chir. 2000 Jan-Feb;55(1-2):39-44.

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