2000 Spontaneously Resolving Appendicitis_Frequency and Natural History in 60 Patients

8/7/2019 2000 Spontaneously Resolving Appendicitis_Frequency and Natural History in 60 Patients

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Gastrointestinal Imaging

Lodewijk P. J. Cobben, M D

Alexander de M ol van

Otterloo, MD, PhDJulien B. C. M. Puylaert, M D,

PhD

S p o n t a n e o u s l y R e s o l v i n g

Ap p e n d i c i t i s: Fr e q u e n c y a n dNa t u ra l H ist o r y i n 6 0 P a t i e n t s 1

PURPOSE: To establish the frequency and natural history of ultrasonographically

(US) documented spontaneously resolving appendicitis following conservative

treatment.

M ATERIALS AND M ETHODS: From July 1987 to July 1997, the authors encoun-

tered 106 patients with US-diagnosed spontaneously resolving appendicitis. We

retrospectively studied clinical data and US findings obtained at admission and

follow-up relating to 60 patients who w ere treated conservatively. Over the same 10

years, 1,280 appendectom iesfor acute appendicitis were performed in the authorshospital.

RESULTS: Of 60 patients, 23 (38%) had recurrent appendicitis after a median of 14

weeks (range, 2254 weeks), w ith 16 (70%) having recurrence with in 1 year of th e

first attack. US findings indicated that patients with an appendiceal diameter of at

least 8 mm were more prone t o recurrence than patients with an appendiceal

diameter of less than 8 mm ; th e recurrence rates were 47% (21 of 45 patients) and

13% (two of 15 patients). The other parameters did not show a statistically

signif icant d ifference.

CONCLUSION: Spontaneously resolving appendicitis occurs in at least one in 13

casesof appendicitis and has an overall recurrence rate of 38%, with t he majority of

casesreccurring within 1 year.

App end icitis is caused by lum inal obstru ction followed by in fection (1). If appen dectom y is

not performed in time, free perforation or the formation of an appendiceal phlegmon or

abscess will generally follow. However, in a minority of patients, symptoms of appendicitis

spontaneously resolve in an early phase of the disease, usually within 2448 hours after the

onset of pain. This phenomenon, which is believed to be caused by relief of obstruction,

ha s be en labe le d sponta ne ously r esolving a ppe ndic itis a nd is f ir m ly doc um e nte d with

ultrason ograph ic (US) follow-up studies (27).

US in these cases depicts a clearly inflamed appendix in patients whose symptoms are

rapidly subsiding or already h ave subsided (Fig 1). Follow-up US stud ies usually demon -

strate a gradual decrease in appendiceal diameter until the appendix has reached normal

dimensions (3). Also, findings of clinical studies endorse the existence of spontaneously

resolving append icitis. From 7% to 25% of patients who un dergo appendectom y for acuteappend icitis men tion a previous episode o f similar symptom s (812).

Tr ea tm e nt of pa tients with sponta ne ously r esolving a ppe ndicitis is c ontr over sial .

Sur geons who de cide to ope r ate de spite subsiding sym ptom s will f ind the ir de c ision

justified by th e path ologist wh o con firms acute appen dicitis, whereas surgeons wh o d ecide

to r em a in c onser vative will f ind the ir de c ision justified by the sponta ne ous r elie f of

symptoms. To our knowledge, no reliable data are available on the recurrence rate after

conservative treatm ent in p atients with spont aneously resolving appen dicitis.

To e sta blish the fr eque nc y a nd na tur a l h istor y of US-doc um e nte d sponta ne ously

resolving appen dicitis following conservative treatmen t, we studied t h e outcom e relating

to 60 patients with US and clinical evidence of appendicitis who were primarily treated

conservatively and who were sho wn clinically to h ave resolution of sympto ms.

Index terms:Appendicitis, 751.291Appendix, US, 751.1298

Radiology 2000; 215:349352

1 From the Departments of Radiol-ogy (L.P.J.C., J.B.C.M.P.) and Surg ery(A.d.M.v.O.), Medisch Centrum Haaglan-den, Lijnbaan 32, 2501 CK The Hague,

the Netherlands. From th e 1998 RSNAscient ific assembly. Received Decem-ber 17, 1998; revision requested Febru-ary 17, 1999; final revision receivedSeptember 7; accepted September 24.Addresscorrespondence to J.B.C. M.P.(e-mail: [email protected]).

RSNA, 2000

Author contributions:Guarantor of integrity of entire study,J.B.C.M.P.; study con cepts and design,L.P.J.C., J.B.C.M.P.; defin it ion of int el-lectual content, L.P.J.C., A.d.M.v.O.,J.B.C.M.P.; literature research, L.P.J.C.;clinical studi es, L.P.J.C., A.d.M.v.O.,J.B.C.M.P.; data acquisition and analysis,L.P.J.C.; statistical analysis, L.P.J.C.; manu-script preparat ion , L.P.J.C., J.B.C.M.P.;manuscript edit ing , J.B.C.M.P.; manu-script review, A.d.M.v.O.

34 9


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MATERIALS AND METHODS

I n our 600- be d c om m unity hospita l , we

h a v e a p o l ic y t h a t e ve ry p a t ie n t w it h

a c ute or suba cute a bdom ina l pa in is a d-

m itted for US evaluation . The patient s in

our study were admitted either by a fam-ily doctor or by a referring doctor at the

emergency department. After the US ex-

amin ation, all patients were examin ed by

a consulting surgeon.

Between July 1987 and July 1997, we

e x am i n e d 1 0 6 p a t ie n t s w it h U S-d i ag -

nosed spontaneously resolving appendici-

tis. The tota l num be r of a ppe nde c tom ies

performed as an em ergency procedure in

this pe r iod wa s 1, 350; in 1, 280 c ases,

th e h istologic diagnosis was acute app en-

dicitis. The h istologic criterion for acute

appendicitis was the presence of polymor-

ph ic granulocytes throughou t th e appendi-

ceal wall, including the muscularis (13). Thecriteria for spontan eously resolving append i-

citis were a clinical history com patible with

acute appendicitis, an enlarged non com-

pressible appendix with a diameter of more

than 6 mm at US, and rapidly subsiding

sympto ms (2,3).

All patients h ad a h istory of right -lower-

qua dr a nt pa in, te nde r ne ss a t pa lpa tion,

r eb o u n d t e n d er n e ss , a n d g u ar d in g . In

addition, two or m ore of the typical clini-

cal signs and symptoms associated with

appen dicitis were present; t hese were ini-

tial periumbilical pain, fever, elevated

white blood cell coun t, nausea, vom iting,

and anorexia. There were n o US or clini-

cal signs of an appendiceal phlegmon or

abscess. There also was no palpable mass

and no elevation of the erythrocyte sedi-

men tation rate associated with t he appen -

dicitis.

Of the se 106 pa tie nts, 29 unde r we nt

surgery immediately, despite improving

sym ptom s: f ive be c a use of a histor y of

r ec ur re nt a tta cks, f our be c a use of the

presence of a fecalith, an d 20 because of

th e surgeon s or p atien ts preferen ce. His-

tologic analysis revealed acute appendici-

tis in all 29.

Of the remaining 77 patients, 13 un der-

went interval appendectomy: three be-

cause of a history of recurrent attacks, one

because of the presence of a fecalith, and

nine because of th e surgeons or the pa-

tients preference. Histologic analysis re-

vealed signs of previous inflamm ation in all

13 removed appendices. These signs in-

cluded focal fibrosis; obliteration of the lu-

men; and diffuse proliferation of p lasma

cells, lymph ocytes, and eosino ph ilic granu-

locytes throughout the appendiceal wall

(13).

Our study con cerns th e clinical and US

long-term follow-up in the 64 remaining

patients with spon taneou sly resolving ap-

pe ndic itis, who we re pr im a rily tr ea te d

con servatively. Th e follow-up w as at least

60 we e ks, a nd the pa tie nts we r e othe r -wise healthy. Four patients were lost to

long-term follow-up.

We (L.P.J.C., J.B.C.M.P.) stud ied th e

c linic a l c ha r ts of the r e m a ining 60 pa -

tients; if n ecessary, we interviewed th e

pa tients or the ir f a m ily doc tors by te le -

ph on e. We recorded each patients sex,

age, duration of symptom s from o nset to

a dm ission, tota l dur a tion of sym ptom s,

eventual use of antibiotics or analgesics,

body te m pe r atur e , leukoc yte c ount, a nd

erythrocyte sedimentation rate at admis-

sion a nd follow-up. M or eove r, we r e-

c orde d whe th e r the pa tient ha d a histor y

of previous attacks, the time of eventual

recurrence, eventual alternative diagno-

sis e xplaining the init ia l sym ptom s, th e

findings at surgery, the histologic find-

ings, and all postoperative complications.

Th e U S i m a ge s w er e i n t er p re t ed b y

con sensus by two radiologists (L.P.J.C.,

J.B.C.M.P.), wh o m easured th e m aximu m

d ia m e te r o f t h e a p p en d i x a n d d e te r-

m ine d the pr e se nc e of pe r ia ppe ndice a l

inf la m e d f at , f e ca lith, a ir in the lum e n,

free fluid, and enlarged mesenteric lymph

nodes (short transverse diameter 5 m m )

both at admission an d follow-up.

Statistical an alysis was performed to

c om pa r e the r e c urr enc e gr oup with the

n o n r ec u rr en c e g r o u p b y u si n g t h e u n -

paired two-tailed Student t test for mean s

a n d t h e 2 test with con tinu ity correction

f or 2 2 tables. Statistical significance

was defined as a P value less than .05.

RESULTS

The study group consisted of 60 patients

with spontaneously resolving appendici-

tis, who were primarily treated conserva-

tively. These 60 patients consisted of 21

female and 39 m ale patients (median age,

29 years; age range, 886 years). The d ata

c onc er ning the f ir st a dm ission we re a s

f ollows: the m e dia n t im e f r om onse t of s ym p t o m s t o a d m i ss io n w as 2 4 h o u r s

( ra nge , 696 hour s). The m e dia n body

t e m p e ra t u r e a t a d m i ss io n w a s 3 7 .4 C

(range, 36.038.6C). Th e m edian leuko-

cyte count was 11.7 10 9/L (ran ge, 5.7

18.2 10 9 /L). The median erythrocyte

sedim e nta tion r a te a t a dm ission wa s 10

m m /h ( ra nge , 131 m m / h) . Thir tee n p a -

tie nts ha d a le ukoc yte c ount of gr e a te r

t h a n 1 2 10 9/L, and five patients h ad an

e r ythr oc yte sedim e nta tion r a te of m or e

th an 20 mm /h . On e patient received anti-

biotics, and two p atients received n on ste-

roidal antiinflamm atory m edication. Fif-

t ee n o f t h e 6 0 p a t ie n t s m e n t io n e d a

histor y of one or m or e pr e vious a tta c ks

(Table 1). Neither the Student t te st nor

th e 2 test sho wed a significan t difference

between th e two groups for th ese data.

US findin gs at adm ission revealed an

e nla rged non c om pr e ssible a ppe ndix in

a ll 60 pa tients. The m e dia n m a xim a l di-

am eter was 8.5 mm (range, 6.513.0 mm ).

Non comp ressible inflamed fat was foun d

a ro u n d t h e a p p en d i x i n 5 1 o f t h e 6 0

a. b. c. d .

Figure 1. Transverse US scans obtained in a

3 0 -y e ar-o ld w o m a n w ith sp o n ta n e o u sly re -

solving ap pendicitis. All figures are on the

same scale, but a, b, an d c were obtained with

o ld er e q u ip m e n t . (a) An inflamed appendix

( ar r ow h e ad s) w i t h a d i a m e t er o f 9 m m i s

depicted; because of rapidly subsiding symp -

toms, however, the patient was not operated

on . (b, c) Images obtained 2 and 4 days after a

sh o w th a t th e a p p e n d ix (a rro w h e a d s) c o n -

stantly decreased in transverse diameter to 7

and 5 mm, respectively. (d ) Follow-up scan

obtained 5 years after a shows a completely

n o rm a l a p p e n d ix (a rro w h e a d s) w ith a d ia m -

eter of 3 mm during compression. The patient

did n ot experience any recurrent symptom s.

35 0 Radiology M ay 2000 Cobben et al


3/4

patients; a fecalith was foun d in 11 of the

60 patien ts. There was evidence of air in th e

lumen in two of the 60 patients, a small

quantity of free fluid n ear the appendix in

six of the 60,an d enlarged mesenteric lymph

n odes in 14 of th e 60 (Table 2).

In 22 of the 60 patients, follow-up US

was performed after a median duration of

3 days (ran ge, 156 days); in n ine of th ese

22 patients, a second follow-up USexami-

n a t io n w a s p e r fo r m e d a ft e r a m e d ia n

du ration of 4 days (range, 228 days) after

the first follow-up examination. The first

follow-up US examination showed a de-

crease in appendiceal diameter in 12 of

t h e 2 2 (5 5 %) p a t ie n t s; t h e se co n d fo l-

l o w-u p U S e xa m i n a ti o n sh o w e d a d e -

crease in eight of the n ine (89%) patient s.

A la te f ollow-up US e xam ina tion wa s

performed after 102580 weeks (median,

2 5 0 w e ek s) i n 1 6 p a t i en t s w h o d i d n o t

un dergo surgery. The app endix could n ot

b e v i su a li ze d i n fo u r a n d h a d n o r m a l

dim e nsions in 12 pa tie nts. The m e dia n

follow-up in the patients who had no recur-

rence was 297 weeks (range, 60580 weeks).

Another diagnosis that explained the initial

symptoms did n ot emerge in any of th ese

patients du ring the follow-up.

Eventually, 23 of the 60 patients had a

r ec ur re nt a tta ck dur ing the follow-up.

O n e p a t ie n t h a d t w o r ec u rr en c e s, o n e

after 124 weeks and the other after 254

weeks. The recurrent attacks occurred after a

median of 14 weeks (range, 2254 weeks).

Sixteen of the 23 patients (70%) had their

recurrent attack within 1 year after the first

admission. This implies th at th e chan ce of

recurrence after 1 year without symptoms

decreased to 16% (seven of 44 patients). Atthe time of recurrence, all patients under-

went US examination of th e appendix th at

revealed signs of app end icitis (Fig 2).

Twenty-two patients with a recurrent

a tta c k unde r we nt im m e dia te a ppe nde c -

tom y; one pa tie nt un de r we nt im m e dia te

a p p en d e ct o m y a ft e r t h e se co n d r ec u r-

rence. Histologic analysis revealed acute

a p pe n d ici tis in a ll 2 3. O n e o f t h e 2 3

p a t ie n t s h a d p e rfo r at io n a t t h e t im e o f

surger y without fur the r c om plica tions;

t h e o t h e r 2 2 p a t i en t s h a d n o c om p l ic a-

tions. The median time of h ospitalization

was 4.8 d ays (range, 315 days).

We studied the difference in the clini-c al a n d US findings be twee n the group

with r e cur r enc e a nd the gr oup withou t

recurrence (Table 2). The 2 test results

s h o w ed a s ig n i fi ca n t l y h i g h e r c h a n c e

(.05 P .02) of recurrence in the group

with appendiceal diameters of at least 8

mm (47% [21 of 45 patients]) than in the

group with dia m e te rs of less tha n 8 m m

(13% [two of 15 patients]). The other param-

eters did not show a significant difference

between th e two group s. Table 1 also sho ws

a slightly higher chance of recurrence in

m ale patient s (41% [16 of 39 patien ts]) than

in female patients (33% [seven of 21 pa-

tients]). Finally, patients with enlarged mes-

enteric lymp h n odes had a lower recurrence

rate (21% [three of 14 patients]) th an pa-

tients withou t en larged mesenteric lymph

nodes (44% [20 of 46 patients]).

DISCUSSION

Spon tan eously resolving appen dicitis is no t

a r ar e p h e n o m en o n . In t h is st u d y, w e

TABLE 1Clinical Parameters in the Total Group of Patients with Spontaneously ResolvingAppendicitis, in the Recurrence Group, and in the Nonrecurrence Group

Clinical FeatureAll Patient s

(N 60)

PatientswithRecurrence

(n 23)

Patientswithout

Recurrence(n 37)

Sex*

Male 39 (65) 16 (70) 23 (62)Female 21 (35) 7 (30) 14 (38)

Age (y)Median 29 32 27Range 886 1086 885

Time from onset of symptoms to US(h)Median 24 18 24Range 696 696 696

Body temperature (C)Median 37.4 37.1 37.5Range 3638.6 3638.4 36.938.6

Leukocyte count (109/L)Median 11.7 13.5 11.0Range (5.718.2) (8.016.6) (5.718.2)

No. of patients with history of previousattacks* 15 (25) 6 (26) 9 (24)

Erythrocyte sedimentation rate (mm/ h)Median 10 7 11

Range 131 131 530

* Number in parenthesesis the percentage of patients.

TABLE 2US Parameters in the Total Group of Patients with Spontaneously ResolvingAppendicitis, in the Recurrence Group, and in the Nonrecurrence Group

USParameterAll Patients(N 60)

Patients withRecurrence

(n 23)

Patientswithout

Recurrence(n 37)

P

Value

Maximum diameter of appendixMedian 8.5 9 8.5 .05*

Range 6.513.0 6.512.0 6.513.0No. of patients with appendicealdiameter8 mm 45 (75) 21 (91) 24 (65) .02.05

No. of patientsw ith inflamed fataround appendix 51 (85) 21 (91) 30 (81) .05

No. of patients with fecalith 11 (18) 3 (13) 8 (22) .05

No. of patientswith air in theappendiceal lumen 2 (3) 1 (4) 1 (3) .05

No. of patients with free fluid 6 (10) 4 (17) 2 (5) .05

No. of patients with enlargedmesenteric lymph nodes 14 (23) 3 (13) 11 (30) .05

No. of patients with appendicealdiameter decreased at firstUSfollow-up 12 of 22 (55) 7 of 13 (54) 5 of 9 (56) .05

Note.Number in parenthesesis the percentage of patients.* Student t test for means. 2 test.

Volume 215 Num ber 2 Spont aneously Resolving Appendicit is: Frequency and Nat ural Hist or y 35 1


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o b se rv ed t h is p h e n o m en o n in 1 06 p a -

tients within 10 years. In th e sam e period,

1,280 appen dectomies that revealed acute

appen dicitis were perform ed. Together with

th e patient s with appen dicitis that spon ta-

n e o u s ly r es o lv e d w i t h o u t su r g er y i n t h e

same period (13 patients with in terval ap-

pendectomy performed, 37 patients with-

o u t r e c u r r e n c e , a n d f o u r p a t i e n t s l o s t t o

long-term follow-up), the total nu m ber of

patients with appen dicitis was 1,321; so,

the frequency of spontaneously resolving

a p p e n d i ci t is i n t h i s s t u d y w a s 8 % . T h i s

could, however, be an underestimation of

t h e t ru e fr eq u e n cy o f t h i s p h e n o m e n o n ,

since some of th e patients who were oper-

ated on also would have had spontaneous

resolution.

The treatment of spontaneously resolv-

ing appen dicitis is controversial because,

t o o u r k n o w l ed g e, t h e re h a v e b e en n o

reliable data on th e recurrence rate after

conservative m anagem ent. We stud ied data

f ro m 6 0 p a t i e n t s w it h a c l in i c al a n d U S

diagnosis of spontaneously resolving ap-

pend icitis who were primarily treated con -

servatively. The follow-up period variedf r o m 6 0 t o 5 8 0 w e e k s , w i t h a m e d i a n o f

297 weeks. A total of 23 of 60 patients (38%)

h a d r e cu r r en t a p p e n d i c it i s. H i st o l o gi c

analysis of the subsequently removed ap-

pend ix demon strated acute appen dicitis in

all 23 patients. Apart from a slightly h igher

chance of recurrence in male patients, in

patients with appendiceal diameters of at

l ea st 8 m m , a n d i n p a t ie n t s w it h o u t e n -

larged mesenteric lymph nodes, no clinical

or US features could be used to predict a

higher or lower chance of recurrence.

O n e c o u l d a r g u e t h a t s o m e o f t h e p a -

t ie n t s i n t h e n o n r e cu r re n c e g r o u p w it h

small appendiceal diameters did not have

appendicitis at all. Fifteen patients had ana p p e n d i ce a l d ia m e t e r o f l ess t h a n 8 m m .

Ten of th e 15 patients h ad US evidence of

periappen diceal inflam ed fat, which is a

con fident sign of append icitis (14). Of the

remaining five patients, four were in the

n o n r e cu r r en c e g ro u p . O f t h e se f o u r p a -

tients, three h ad a decrease in append iceal

diameter (diameter 6 m m ) o b se rv ed

during follow-up US, which indicated that

indeed appendicitis had been present. In

on e patient, we did n ot perform USfollow-

up; so, we cannot exclude the possibility

t h a t t h i s p a t ie n t in fa ct d id n o t h a ve

app end icitis at all.

Th e p r e se n c e o f e n l a rg ed m e s en t e r i c

lymph nodes was associated with a lowerr a t e o f r e c u r r e n c e . O n e c o u l d a r g u e t h a t

th ese lymph no des were associated with

a n o t h e r b o w e l c o n d i t io n , s u ch a s i n f ec -

tious ileocecitis or Crohn disease. In these

conditions, however, we would expect to

visualize conspicuous wall thickening in

th e ileum an d cecum (15). Apossible expla-

nation for the lower rate of recurrence in

t h e g r o u p w i t h e n l ar ge d l y m p h n o d e s i s

t h e e x i s t i n g t h e o r y ( 1 3 ) t h a t o b s t r u c t i v e

a p p en d i ci ti s c a n b e se co n d a r y t o l ym -

ph oid h yperplasia in the appen diceal wall.

Ly m p h o i d h y p e rp l asi a w il l a lso b e r e-

f le ct e d b y e n l a rg ed m e s en t e r ic l ym p h

n o d e s . O n e c o u ld a ss u m e t h a t t r a n s ie n t

lymph oid hyperplasia, as a cause of obstruc-

tive appendicitis , has a lower tend ency to

recur th an oth er causes of m echanical ob-

struction.

It is difficult to give therapeutic recom-

men dations with a recurrence rate of 38%

after spontan eously resolving appen dici-

t is. W it h o n e o f o u r 2 3 p a tie n ts w it h

recurrent appendicitis having perforating

a p p e n d i ci t is a t t h e t i m e o f t h e o p e r a t io n ,

man y surgeon s will consider a 38% rate of

recurrence an ind ication to operate im me-

diately on an y patient with spontan eously

resolving append icitis . In the subgroup of

m a l e p a t i en t s w i t h a n a p p e n d i ce a l d ia m -

e te r o f a t le ast 8 m m a n d n o e n la rg ed

mesenteric lymph nodes, the expected re-

c u r r e n c e r a t e o f 6 0 % ( 1 2 o f 2 0 p a t i e n t s )appears to be a fair ind ication for imm edi-

ate surgery.

Neverth eless, patients wh o are com pletely

f re e o f s y m p t o m s m a y b e r e l u ct a n t t o l et

them selves be operated on. In view of the

fairly high recurrence rate, patients wh o

opt for conservative management must be

warned to seek imm ediate medical help in

case of recurrent symptoms. Spontaneously

resolving append icitis occurs in at least

on e in 13 cases of appendicitis and h as an

o v e ra ll r ec u r re n c e r a t e o f 3 8 % , w i t h t h e

majority of cases reccurring within 1 year.

Acknowledgments: We are indebted to Arian

R. van Erkel, MD, for h is help with th e statisti-cal analysis of our data.

References

1. Wangen steen OH, Bowers WF. Significance of

o b s tru c tiv e f a c to r in th e g en e s is o f a c u te

append icitis: experimental study. Arch Surg

1937; 34:496526.

2. Jeffrey RB, Laing FC, Townsend RR. Acute

append icitis: sonographic criteria based on250 cases. Radiology 1988; 167:327329.

3 . M igr a in e S, Atr i M , B r et P M, L o u g h JO,

Hinchey JE. Spontaneously resolving acute

append icitis: clinical and sonographic docu-

mentation. Radiology 1997; 205:5558.

4. Oom s HWA, Kouman s RMJ, Ho Kang You PJ,Puylaert JBCM. Ultrasonography in the diag-

nosis of appendicitis. Br J Surg 1991; 78:315

318.

5. Puylaert JBCM. Acute appen dicitis: US evalu-

ation using graded com pression. Radiology

1986; 158:355360.6. Puylaert JBCM, Rutgers PH, Lalisang RI, et al.

A p r o s p e c tiv e s tu d y o f u ltr a s o n o g r a p h y in

the diagnosis of appendicitis. N Engl J Med

1987; 317:666669.

7 . Rio u x M . So n o g r a p h ic d e te ctio n o f th e n o r -

mal and abn ormal appendix. AJRAm J Roent-genol 1992; 158:773778.

8. Barber MD, McLaren J, Rainey JB. Recurrent

appen dicitis. Br J Surg 1997; 84:110112.

9 . C r ab b e M M , No r wo o d S H, R o be r tso n HD,Silva JS. Recurrent and chronic appendicitis.

Surg Gynecol Obstet 1986; 163:1113.10. Ferrier PK. Acute app endicitis in un iversity

students: a twen ty year study of 1028 cases. J

Am Coll Health Assoc 1972; 20:287290.

11. Lewis FR, Holcroft JW, Boey J, Dun ph y E.

Append icitis: a critical review of diagnosis

and treatment. Arch Surg 1975; 110:677684.12. Mattei P, Sola JE, Yeo CJ. Chro nic an d recur-

rent appendicitis are uncommon entities of-

te n mis d ia g n o se d . J Am C o ll Su r g 1 9 9 4 ;

178:385389.

1 3 . Ro s ai J. C h a p te r 1 1 : Ap p e n d ix . I n : Ack e r-

ma n s s u r g ic a l p a th o lo g y. St Lo u is , M o :Mosby, 1996; 711716.

14. Rao PM, Rhea JT, Novelline RA. Sensitivity

and specificity of th e ind ividual CT signs of

appendicitis: experience with 200 h elical ap-

pendiceal CT examination. J Comput AssistTom ogr 1997; 2:686692.

15. Puylaert JBCM, Van der Zant FM, Mutsaers

JA. Infectious ileocecitis caused by Yersinia,

Campylobacter, an d Salmonella: clinical, radio-

logical and US findin gs. Eur Radiol 1997;

7:39.

a. b.

c.

Figure 2. Longitudin al USscans obtained in a

29-year-old m an with spontan eously resolving

appendicitis and recurrence. (a) U S sca n o b -

tained at adm ission reveals an in flamed appen-

d ix (a rro w h e a d s) w ith a d ia m e te r o f 1 0 m m .

Because symp tom s were rapidly subsiding, th e

su rge o n s d e c id ed n o t to o p e rate . (b) US scan

obtained 4 days after a sh o w s th a t th e a p p e n d i-

c ea l d ia m e te r d e cre ased to 5 m m . T h e a p p e n -

d i x w a s c o m p r es si b le , a n d t h e p a t ie n t w a s

completely symptom free. (c) Repeat US scan

obtained 14 weeks after b, w h e n t h e p a t i e n t

had recurrent sympt om s of append icitis, shows

a n in fla m e d a p p e n d ix w ith a d ia m e te r o f 1 0

mm (arrowheads). Subsequent appendectomy

revealed acute appendicitis.

35 2 Radiology M ay 2000 Cobben et al

2000 Spontaneously Resolving Appendicitis_Frequency and Natural History in 60 Patients

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Transcript of 2000 Spontaneously Resolving Appendicitis_Frequency and Natural History in 60 Patients