Acute appendicitis

Important point to do this case study:
?    Please write introduction about acute appendicitis put in text citation for example (Johon 2002, 34) 34 is page number
?    Patient history and diagnosis: I add original text that related to the topic please read the original text and paraphrase the good point to complete the paragraph 2.
?    Paragraph three is about the anatomy of normal appendix please read, improve the language used I did paraphrase for it but I feel its language need improvement.
?    Paragraph 4: is about risk factors and pathology of appendicitis I add original text from two different article please read both select the good points and do paraphrase for them (because I copy it from the article)
And I add the in text citation for the source I selected. And about the pathology I put 2 sources in the box but the third one you find in as an attached pdf. file (read both select the good points do paraphrase and in text citation.
?    Paragraph 5 is about the imaging modality for diagnosis the acute appendicitis, please read the source select the good points from different sources that I put under each modality and do paraphrase and in text citation as I wrote.
?    Paragraph 6 I add one source in the box and the second source is as attached file please read both select the good point about trat the case and do paraphrase for the point that you see it is good at treat the acute appendicitis. and please write around 100 words about the prognosis of acute appendicitis and do in text citation as I do and bibliography as I did (follow Chicago 16th ed. author date style )
?    Conclusion is summary for the points mentioned above.
?     Please add reference to become 10 references. And follow the style as I did
?    I want it plagiarism free
?    Total words no more than1750 words
?    Chicago 16th ed. style


2-Patient history and diagnosis:
(Please add general symptom for this disease and how it will be diagnosed from the text below but do paraphrase and it should be related to this case study selectedeg he has fever and vomiting his blood investigation shows increase in the white blood cells…)

A 26 years male patient presented with severe pain in his right lower abdominal area and irradiated to middle and the contralateral side of his abdomen.( include possible symptoms, physical examination and laboratory test for this patient fro the text below)
Do paraphrase to the text below to complete the paragraph (diagnosis):
Original text:
In text reference:(Ishikawa 2003, 218-219).
Bibliography is: (Ishikawa, Hiroshi. 2003. “Diagnosis and Treatment of Acute Appendicitis.” Acute Appendicitis 46(5): 217-221. )
Diagnosis of Acute Appendicitis:
Clinical manifestations
Abdominal pain, fever, and anorexia are clas- sical symptoms. Pain occurs in the upper abdo- men at first. It then moves slowly and localizes to the right lower quadrant. In many cases, a fever of around 38°C is present.
Findings on physical examination
Physical examination is the most useful method for diagnosing appendicitis and for determining whether an operation is necessary. Tenderness can be elicited at various points in the right lower quadrant of the abdomen, including McBurney’s, Lanz’s, and Munro’s points (Fig. 1). Among the indications for sur- gical treatment, the presence of peritoneal irri- tation is critical. Operation is indicated when Blumberg’s sign is positive (the pain elicited by steadily increasing pressure at the site of tenderness increases on abrupt release of the pressure), and when Rosenstein’s sign is elic- ited (tenderness in the right lower quadrant increases when the patient moves from the supine position to a recumbent posture on the left side). As a matter of course, the detection of abdominal muscular guarding and tender- ness on rectal examination are among the sur- gical indications.
Laboratory tests
The white blood cell count (WBC) and CRP are of diagnostic value. The WBC usually exceeds 10,000/mm3. In severe cases associated with diffuse peritonitis, however, the WBC may be decreased rather than increased, so care must be taken. Although the CRP rises in appendicitis, the increase is not necessarily associated with the severity of inflammation.

3-Anatomy of appendix:(check grammar and it also need proofreading and if you can add other anatomical information it will be ok
The appendix is a part of large intestine and vermiform in shaped connected to the inferior- posterior part of the is also located approximately 2.5 cm inferior to the junction of ilium part of small intestine and the caecum of large intestine (figure 1). Moreover, appendix is variable in length and it ranges between around 7mm and 10 cm and its location also variable but the most common location is posterior to the caecum. However, in some cases the appendix can be long and it locates posterior to ascending part of colon and it also can be located in pelvic area or in subcaecal, which projects inferiorly below caecum or behind the ilium of small intestine (Ellis 2010, 1).

Figure 1 shows the possible anatomical position of the appendix ((Ellis 2010, 2).
The appendicular artery supplies blood to the appendix and this artery emerge from the ileocolic blood vessels (Figure 2). This artery passes posterior to the ilium of small intestine through the mesenteric of appendix. On the other hand the presence of inflammation within the appendix may result in thrombosis formation in the appendicular artery and may cause gangrene. That means the appendix does not have a collateral blood supply like some other organ such as gallbladder (Ellis 2010, 1).

Figure 2 illustrates the arterial blood supply of appendix (Ellis 2010, 1).

4-( a-risk factors) and (b-pathology):

( a-risk factors)
In this square I put two original texes talking about the risk factors please read them and write about the risk factors of acute appendicitis from them but please do paraphrase :
1-First original text for risk factors
In text reference is: (Simpson and Scholefield 2005, 213)
Bibliography is: (Simpson, John and  John H.Scholefield. 2005. “ Acute appendicitis.” Surgery23(6): 213-216. doi: 10.1383/surg. )

The vermiform appendix is a vestigial structure measuring 7.5- 10 cm in length in an adult. Morphologically, it represents the underdeveloped distal part of the large caecum present in many lower animals. The exact cause of acute appendicitis is unclear, but luminal obstruction, diet and familial factors have been suggested; the cause may be multifactorial in some cases.
2- second original text for risk factors:
In text reference is: ( Singh 2013, 27)
Bibliography is: (Singh, Ajay. 2013. Emergency Radiology: Imaging of Acute Pathologies. New York: Springer. )

Appendicitis is most often due to luminal obstruction fol- lowed by bacterial invasion. Appendiceal obstruction can be caused by an appendicolith, foreign body, strictures, lym- phoid hyperplasia, or rarely parasitic infections . If obstruction persists, the intraluminal pressure in the appendix may rise above that of the veins, leading to venous obstruc- tion and appendiceal wall ischemia.

B- pathology overview:
?    First original text about pathology overview:
In text reference: (Ishikawa 2003, 218-219).
Bibliography is: (Ishikawa, Hiroshi. 2003. “Diagnosis and Treatment of Acute Appendicitis.” Acute Appendicitis 46(5): 217-221. )

Pathology of Acute Appendicitis
The cause of appendicitis is considered to be obstruction of the appendiceal lumen and the subsequent onset of bacterial infection. Lumi- nal obstruction can be produced by various mechanisms and it results in the retention of mucus. If bacterial infection supervenes, the intraluminal pressure increases, leading to interruption of lymphatic flow and the develop- ment of appendiceal edema. This process leads to acute appedicitis characterized by distension of the appendix and vascular congestion, which is designated as catarrhal appendicitis. If this condition progresses further, appendiceal edema and vascular congestion become pronounced with the formation of multiple abscesses in the wall and purulent fluid on the serosal surface. This condition is designated as phlegmonous appendicitis. If it progresses further and causes local circulatory dysfunction, this will result in infarction opposite the junction between the mesoappendix and appendix, where the blood supply is inadequate. As a result, the appendix becomes congested dark red with black necrotic areas, a condition that is designated as gangre- nous appendicitis. If perforation of the necrotic wall occurs, appendicitis becomes complicated by perforative peritonitis. Usually, peritonitis is localized, being confined to the ileocecal region. In young children, however, the omentum is not fully developed, so the clinical course is often complicated by diffuse peritonitis.

?    Second original text about pathology overview:
In text reference is: ( Singh 2013, 27)
Bibliography is: (Singh, Ajay. 2013. Emergency Radiology: Imaging of Acute Pathologies. New York: Springer. )

Pathological Stages of Appendicitis: Three Stages
1. Acute catarrhal appendicitis: There is early scant neutro- philic infiltrates without perforation. The inflammation of the appendix can spontaneously regress or progress to the second stage.
2.    Purulent (phlegmonous) stage: Neutrophilic infiltrate, ulceration, and necrosis are seen. Spontaneous regression is rare and there is progression to appendiceal perforation.
3.    Gangrenous stage: Necrosis, ulceration, gangrene, and peritoneal inflammation are seen without the possibility of spontaneous regression.

Third original text about the pathology overview:
I attached the source you can find it as an attachment file
(In text reference is: (Simpson and Scholefield 2005, 213)
Bibliography is: (Simpson, John and  John H.Scholefield. 2005. “ Acute appendicitis.” Surgery23(6): 213-216. doi: 10.1383/surg. )

5- Imaging Modalities in the diagnosis acuteappendicitis:
Acute appendicitis can diagnose by the radiography(less helpful), computed tomography(better), ultrasound, Magnetic resonance imaging:
General radiography:
First original text about using general radiography in diagnosis acute appendicitis:
(In text reference: (Ishikawa 2003, 218-219).
Bibliography is: (Ishikawa, Hiroshi. 2003. “Diagnosis and Treatment of Acute Appendicitis.” Acute Appendicitis 46(5): 217-221. )
Plain abdominal radiographs show no par- ticular evidence of appendicitis. If an air-fluid level is seen in the lower abdomen, however, localized peritonitis should be suspected. Ultra- sonography and CT scanning are of diagnos- tic value, and provide useful information for determining whether or not appendectomy is necessary.)

Second original text aboutusing general radiography in diagnosis acute appendicitis:
(In text reference is: (Simpson and Scholefield 2005, 215)
Bibliography is: (Simpson, John and  John H.Scholefield. 2005. “ Acute appendicitis.” Surgery23(6): 213-216. doi: 10.1383/surg. )

Plain radiographs are unhelpful in diagnosis, but are used to exclude other causes of abdominal pain. Most of the changes seen in some cases of acute appendicitis (e.g. haziness in right iliac fossa, dilated loops of ileum) are nonspecific. However, abdominal radiographs can occasionally show an appendicular faecolith and, because up to 50% of children aged less than 2 years have been reported to have a visible faecolith, a plain radiograph of the abdomen may be a useful diagnostic tool in this age group.)
Third original text aboutusing general radiography in diagnosis acute appendicitis:
( in text reference 🙁 Eisenberg and Johnson 2012, 185).
Bibliography: (Eisenberg, Ronald L., and Nancy M. Johnson.2012. Comprehensive Radiographic Pathology. 5th ed. St.louis,Missouri : Mosby.)
Plain abdominal radiographs demonstrate around or oval, laminated calcified fecalith in appendix (appendicolith) in about one third of patients. Surgical experience indicates that the presence of an appendiclith in combination with symptoms of acute appendicitis usually implies that the appendix is gangrenous (necrotic) and likely to perforate. Most appendicoliths are located in the right lower quadrant overlying the iliac fossa.Depending on the length and position of the appendix, however, an appendicolith can also be seen in the pelvis or in the right upper quadrant (retrocecal appendix), where it can simulate a gallstone. Because of the danger of perforation, barium enema examination is usually avoided in acute appendicitis. if it is performed, an irregular impression of the base of the cecum (caused by inflammatory edema), in association with failure of barium to enter the appendix, is a characteristic finding. Nevertheless, failure of barium to fill the appendix is not a reliable sign of appendicitis, because the normal appendix does not fill with barium in about 20% of cases. Partial filling of the appendix with distortion of its shape or caliber strongly suggests acute appendicitis, especially if there is a cecal impression. In contrast, a patent (open) appendiceal lumen effectively excludes the diagnosis of acute appendicitis, especially when barium extends to fill the rounded appendiceal tip)

Computed tomography:
First original text for using ct in diagnosis acute appendicitis:
In text reference is: ( Singh 2013, 27)
Bibliography is: (Singh, Ajay. 2013. Emergency Radiology: Imaging of Acute Pathologies. New York: Springer. )

Currently, the majority of patients with clinically suspected appendicitis undergo intravenous contrast-enhanced CT with or without oral or rectal contrast before the surgery.
Imaging Findings on CT
1-Appendiceal caliber: 7 mm or more in width. This crite- rion alone does not have high positive predictive value because up to 42 % of normal population can have an appendiceal caliber of more than 7 mm.
2-Appendiceal wall thickness of more than 3 mm.
3-Appendiceal mural enhancement, homogeneous or stratified appearance of the appendiceal wall (Fig. 3.4).
4.    Lack of intraluminal contrast in the appendix.
5.    Periappendiceal inflammation.
6.    Appendicoliths(Fig. 3.5): It is seen in 10 % cases on ?plain radiograph and 30 % on CT study. The detection of an isolated appendicolith on CT is not sufficiently specific to be the sole basis for the diagnosis of acute appendicitis [7]. The use of bone window setting can increase the detection rate of appendicolith [8].
7.    Arrowhead sign: Arrow-shaped configuration of the cecum due to funneling of intraluminal contrast into the
spastic cecum (Fig. 3.6). It is an indicator of extension of
inflammation from the appendix to the cecum.
?8. Cecal bar sign: It is characterized by edema and bar-like thickening of the cecum at the base of the appendix
?9. Hyperdense appendix: Hyperdense appendix is seen as
high-attenuation appendix on noncontrast CT and is
seen in 33 % of patients with acute appendicitis [9].?
10. Maximum depth of intraluminal appendiceal fluid of more than 2.6 mm: This can be useful in diagnosis of appendicitis when no periappendiceal inflammation is
present [10].
The five specific CT findings of perforated appendicitis are [1. Extraluminal air?
2. Extraluminalappendicolith
3. Abscess?  4. Phlegmon?   5. Defect in the enhancing appendiceal wall (sensitivity,
64 %)
The secondoriginal text for using ct in diagnosis acute appendicitis:
( in text reference 🙁 Eisenberg and Johnson 2012, 185).
Bibliography: (Eisenberg, Ronald L., and Nancy M. Johnson.2012. Comprehensive Radiographic Pathology. 5th ed. St.louis, Missouri : Mosby.)

CT, the gold slandered, shows an appendiceal abscess as around or oval mass of soft tissue density that may contain gas. After administration of IV contrast material, the appendix appears as a dilated structure with a thickened, circumferentially enhancing wall. This modality provides a more precise evaluation of the nature, extent, and location of the pathologic process and can detect intraabdominal disease unrelated to appendicitis that may explain the patient’s clinical presentation.

First original text for using ultrasound in diagnosis acute appendicitis:
In text reference is: (Singh 2013, 27)
Bibliography is: (Singh, Ajay. 2013. Emergency Radiology: Imaging of Acute Pathologies. New York: Springer. )

Ultrasound Imaging
Graded-compression ultrasound with curvilinear probes is often performed with a 3.5-MHz transducer in larger patients and 5 MHz in thinner patients. Graded-compression ultra- sound is performed in the transverse plane from the tip of liver to the pelvic brim, followed by scanning in sagittal and oblique planes. The ultrasound scanning uses uniform pres- sure to displace gas-filled bowel from the field of view. The normal appendix can be usually seen in the majority of chil- dren but in only a minority (<10 %) of adults. The presence of appendiceal perforation, leading to decompression and collapse of the appendiceal lumen, is believed to decrease the sensitivity of ultrasound in diagnosing acute appendici- tis. In general, the sensitivity of ultrasound (74.2 %) in the diagnosis of acute appendicitis is lower than the sensitivity reported with CT (100) [12]. In meta-analysis of head-to- head comparison studies performed between 1966 and 2006, the sensitivities of CT and graded-compression ultrasound studies were 91 and 78 %, respectively [13].
Ultrasound Findings of Acute Appendicitis
8.    Noncompressible and aperistaltic blind-ending tubular structure (Fig. 3.11).
9.    Appendiceal caliber >6 mm between outer borders of tunica muscularis.
10.    Appendicolith, indicated by clean distal acoustic shadowing.
11.    Inflamed fat causes “echogenic mass effect”.
12.    Increased blood flow in appendiceal wall, compared to ?normal gut on color Doppler ultrasound.
Second original text for using ultrasound in diagnosis acute appendicitis:
( in text reference 🙁 Eisenberg and Johnson 2012, 185).
Bibliography: (Eisenberg, Ronald L., and Nancy M. Johnson.2012. Comprehensive Radiographic Pathology. 5th ed. St.louis, Missouri : Mosby.)

When clinical presentation is unclear, high- resolution ultrasound with graded compression is the imaging modality of choice for diagnosing acute appendicitis, especially when use of ionizing radiation is contraindicated in the patient. A noncompressed appendix measuring 7mm op more in maximal outer diameter is considered virtually pathognomonic of acute appendicitis.

Finally MRI imaging:
In text reference is: (Singh 2013, 27)
Bibliography is: (Singh, Ajay. 2013. Emergency Radiology: Imaging of Acute Pathologies. New York: Springer. )

original text for using MRI in diagnosis acute appendicitis:
MR is the imaging modality of choice in pregnant patients when ultrasound is nondiagnostic or equivocal. We use a four-sequence protocol, which includes T2 single-shot fast spin echo (SS-FSE), T2 FSE, short tau inversion recovery, pre-gadolinium T1, and post-gadolinium T1 sequences [15]. Three-plane SS-FSE used to localize the appendix, followed by STIR and FSE T2-weighted sequences. STIR is poor at identifying the normal appendix but excellent for identifying early edema and inflammation. STIR has high sensitivities in identifying pathologies with high T1 and T2 relaxation times.
Intravenous gadolinium-based contrast material is used only if the patient is not pregnant because gadolinium is classified as class C drug and is known to cause teratogenic effects in animals. The appendix is visualized on MR in 70–100 % of patients, as opposed to 90–100 % cases on CT. The sensitivity of MR for acute appendicitis is reported to be 75–100 % [15–23].
The MR findings of acute appendicitis include dilated appendix, periappendiceal inflammation, appendiceal wall thickening, and intense enhancement of the appendix

6- Treatment and prognosis:
acute appendicitis is treated surgically by removing appendix (asppendectomy)
First original text about treatment of appendicitis:
Surgical therapy
(In text reference: (Ishikawa 2003, 218-219).
Bibliography is: (Ishikawa, Hiroshi. 2003. “Diagnosis and Treatment of Acute Appendicitis.” Acute Appendicitis 46(5): 217-221. )

Phlegmonous or more advanced appendicitis should be treated surgically. Ultrasonographic findings are the most important factor for deciding whether surgery is necessary. In addition to the symptoms of phlegmonous appendicitis described above in the section on diagnosis, the presence of ascites or an abscess indicates the necessity for surgery. Among the abdominal findings on physical examination, the presence of peritoneal irritation is critical. If this is positive, an operation is indicated.
In the field of surgery for acute appendicitis, laparoscopic appendectomy is attracting much attention (Fig. 3). This procedure has become established in Japan and other countries. Although its usefulness has been gradually accepted, whether it is superior to conventional open appendectomy remains controversial, so it is not yet considered to be a standard therapy for acute appendicitis. The advantages and drawbacks of this procedure are described next. For the technical details that are not described in this article, see the relevant text- books and reports.
For the patient, the advantages of laparoscopic appendectomy are reported to include decreased postoperative pain, faster recovery of muscle tone, earlier return to normal activities, minimal scarring, a low risk of wound infection, no ventral hernia, and a reduced risk of postoperative adhesions.4) On the other hand, conventional open appendectomy seldom causes problematic postoperative pain, scarring, or ventral hernia. In other words, the laparoscopic and open procedures may only be different in their degree of difficulty.
From the standpoint of the surgeon, laparoscopy is useful to rule out appendicitis in patients with confusing symptoms. Also, if a diagnosis of appendicitis is established, wide- ranging examination of the peritoneal cavity becomes possible. Furthermore, intraperitoneal cleansing of the site can be done under vision on the monitor. It has even been reported that a drain could be inserted and placed appropriately under laparoscopic vision.4)
Drawbacks of laparoscopic appendectomy include the necessity for general anesthesia, the need for special apparatus including an insufflator to create pneumoperitonium, the need for more staff including surgeons and anesthesiologists, and the risk of complications due to special procedures for laparoscopic surgery such as peritoneal insufflation and insertion of trocars.?The greatest merit of laparoscopic appendectomy is being “minimally invasive.” Because conventional open appendectomy is already relatively simple and not so invasive, however, this merit itself is not highly attractive. In particular cases, such as obese patients, young female patients seeking a better cosmetic out- come, and patients with suspected appendicitis who may have other conditions, it would seem that laparoscopic appendectomy may be useful.)
The second source (original text for treat acute appendicitis I will attach it as a pdf file please take the information from both text and do paraphrase for them:
(In text reference is: (Simpson and Scholefield 2005, 215-216)
Bibliography is: (Simpson, John and  John H.Scholefield. 2005. “ Acute appendicitis.” Surgery23(6): 213-216. doi: 10.1383/surg. )

write about the prognosis of appendicitis and put references (

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