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\title{Management of Acute Appendicitis in Covid Pandemic-A Prospective Study of 25 Cases}
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             \author[1]{Dr. Abhishek  Mahadik}

             \author[2]{Dr. Meena  Kumar}

             \author[3]{Dr. Nida  Khan}

             \author[4]{Dr. Manish  Kumar}

             \author[5]{Dr. Meenal  Mapari}

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\date{\small \em Received: 9 December 2019 Accepted: 5 January 2020 Published: 15 January 2020}

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\begin{abstract}
        


Acute Appendicitis is a surgical emergency. Patients present with pain in right lower abdomen, with other symptoms like nausea/vomiting, fever, diarrhoea, urinary symptoms. Diagnosis is based on a multimodality approach that includes, clinical, radiological and pathological findings. Alvarado Score helps determine the severity of infection, confirm diagnosis and guide further management. Management is either conservative with antibiotics or surgical depending on severity. However approach to surgical management has changed with the ongoing Covid-19 pandemic. It has necessitated categorisation of surgical procedures into essential and non essential to limit risk to both patient and surgical team and also for prioritization of resources to the rising, continued spread of Covid-19. We present a prospective study of 25 cases of appendicitis presenting during the Covid Pandemic between 15th March and 30th May to our hospital, with an intent to try conservative management for all patients except in the presentations with complications like perforation, abscess or the presence of fecolith or poor response to conservative management. Patients not amenable to conservative management were treated by Open appendicectomy.

\end{abstract}


\keywords{acute appendicitis, Covid-19, alvarado score, appendicectomy.}

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\let\tabcellsep& 	 	 		 
\section[{Introduction}]{Introduction}\par
cute appendicitis is a surgical emergency. It is the most common cause of acute abdomen in North America, with approximately 1/3 rd presenting with perforation at presentation. Incidence is 84/100000 population. \hyperref[b0]{1} CT is gold standard for imaging in acute appendicitis, however associated with increased radiation exposure. Alvarado Score is used to predict the severity of appendicitis, and uses clinical symptoms, signs and laboratory markers and negates the need for radiation exposure. \hyperref[b1]{2} Management of appendicitis is either conservative or surgical. Conservative management can be tried for non complicated appendicitis, whereas presence of complications like perforation, fecolith, abscess dictate surgical management. \hyperref[b2]{3,}\hyperref[b3]{4} However, the Covid-19 pandemic changes routine surgical management. Operating theatres are high risk areas for transmission, additional strain on the team and resources due to increasing prevalence of Covid-19, risk to operating team has called for a change in protocols to determine essential vs non essential procedures. Proper education of surgical staff regarding use of PPE and decreased exposure of healthcare staff is the key to minimising risk of infection in the team. \hyperref[b4]{5} Uncomplicated appendicitis can be managed with antibiotics and monitored for improvement in symptoms, signs and hemogram for leucocytosis. Complicated cases that cannot be otherwise conserved can be operated taking all the necessary precautions such as pre operative COVID-19 testing, including Personal Protective Equipment (PPE) for operating team, limiting the members of operating team, proper operating room ventilation and air purification, dedicated Covid-19 positive and Covid-19 suspect wards, clear path for transport with limited traffic are the need of the hour. Laproscopic surgeries carry higher risk over open surgeries due to the risk of aerosol transmission.  {\ref 6} . 
\section[{II.}]{II.} 
\section[{Material and Method}]{Material and Method}\par
A Prospective study was done on all patients presenting to Dr. D.Y Patil Hospital, Navi Mumbai, India with clinical features of acute appendicitis during covid pandemic, from 15th March to 30 th May. 
\section[{Inclusion Criteria}]{Inclusion Criteria}\par
1. Patients presenting with clinical features of acute appendicitis, diagnosed clinically and confirmed on ultrasonograpy and evident as leucocytosis on hemogram were included in the study. 2. Patients willing to participate in the study. 3. Patients who followed up for 7 days after discharge. 
\section[{Exclusion Criteria}]{Exclusion Criteria}\par
1. Patients not willing to participate in the study. 2. Patients who did not follow up after discharge.\par
All patients presenting with right iliac fossa during the above stated period were evaluated. Following parameters were noted for all patients and compared.\par
Patients above 15 years of age were included in the study. Thorough history taking and examination was done for the patients. Presenting symptoms of pain in abdomen, nausea/vomiting, fever, loss of appetite, loose stools, urinary frequency were evaluated. History of recent travel, contact with covid positive or covid exposed patients was asked for. Any significant co I morbidities and past surgical histories were noted. Covid swab was sent for all patients on admission. Complete physical examination was done for the patients. Pulse rate, Blood Pressure examination, Per abdominal examination was done to look for tenderness and its site, presence of any guarding or rigidity. Chest Xray was done for all the patients to rule out features of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), including atypical or organising pneumonia, often with a bilateral, peripheral, and basal predominant distribution. A hemogram was done for all patients. Ultrasound examination was done for all patients, including diameter of appendix, periappendiceal fat stranding or collection with other features such as presence of appendiculoliths, gas within the lumen of appendix, loculated collection and appendicular phlegmon were noted. Based on ultrasound findings, patients were classified into Group A and B, Group A had cases of uncomplicated appendicitis that were conserved, whereas Group B had cases of Complicated appendicitis including, appendiculolith, appendicular perforation, appendicular abscess. Patients of group A who did not respond to conservative management within 24-48 hours were operated and included in group B.\par
Conservative management included, keeping the patient nil per oral for 48 hours with intravenous antibiotics for 3-5 days, shifted to oral antibiotics after that.\par
These patients were regularly examined for worsening of clinical signs including change in abdominal examination findings, with repeat leucocyte count being done at 48 hours. One patient in Group A did not improve after 48 hours and was taken up for surgery.\par
Patients operated were treated will all precautions and use of PPE and open appendectomy was done. Laproscopic appendectomy was not done due to increased risk of aerosol exposure to operating team. Patients were given intravenous antibiotics for 3 days in view of complicated appendicitis, then shifted to orals. Patients were kept nil per oral for two days after surgery, then shifted to orals. Suture removal was done on POD 10.\par
All patients were tested for Covid-19, and turned out to be negative.\par
All patients were followed up for 7 days after discharge, with plan to follow up if symptomatic in the future.\par
Patients with appendicular lump were asked to follow up after 4 weeks, and before that if symptomatic. 
\section[{III.}]{III.} 
\section[{Result and Discussion}]{Result and Discussion}\par
Out of 25 patients, 15 were males and 10 were females. It was observed that 64\% of patients were in the age group of 15-25 years. All 25 patients presented with pain in right iliac fossa, while 10 \% had accompanying nausea/ vomiting. 40\% patients had a 24-48h history of pain in abdomen, 24\% patients had a 48-72h history, 12 \% had a history of >72h and 8\% had <24h history of pain in abdomen. In Group A, 89\% patients had an Alvarado Score of 7-10, 11\% had a score of 5-6 and were conserved. Group B that underwent surgical management had an Alvarado score of 7-10 in 66.66\% patients and a score of 5-6  
\section[{in 33.33\% patients. Out of 25 patients, 6 patients who underwent operative management had adverse clinical signs on presentation, with leucocytosis or worsening after admission or appendicular perforation as presentation.}]{in 33.33\% patients. Out of 25 patients, 6 patients who underwent operative management had adverse clinical signs on presentation, with leucocytosis or worsening after admission or appendicular perforation as presentation.}\par
The first historical description of appendix and its inflammation dates back to the 16 th century. The first appendectomy was described by Amyand in 1736, when he discovered inflamed appendix in a patient of hernia with enterocutaneous fistula. \hyperref[b8]{7} Appendix is a blind muscular tube, with mucosa, submucosa, muscular and serosal layers. It is short and broad at birth, then becomes tubular by 2 years of age. Appendix comes to lie in retrocaecal position as the caecum grows and appendix rotates. Failure of this rotation results in pelvic, subcaecal and paracaecal positions. The base of the appendix, however remains constant, at the confluence of the three tenia, and can help find the appendix intraoperatively by tracing anterior tenia. \hyperref[b9]{8} Appendicitis is inflammation of appendix. Etiology of appendicitis includes decreased dietary fibre, increased consumption of refined carbohydrates and often luminal obstruction by fecolith or stricture. Pathology of appendicitis involves obstruction of lumen, lymphoid hyperplasia, increased intraluminal pressure, oedema and mucosal ulceration, venous obstruction and ischemia of appendix wall leading to gangrene and perforation. Infection may get contained by antibiotics or greater omentum and loops of small bowel become adherent to inflamed appendix and form a phlegmonous mass or paracaecal abscess. Risk   \hyperref[b11]{10} . Presentation as appendix mass is conserved with antibiotics. \hyperref[b12]{11} Covid-19 is caused by SARS-COv-2, known commonly as coronavirus. It is responsible for an outbreak beginning in Wuhan in December 2019, then spreading to majority of the world. It causes asymptomatic infection to mild pneumonia like illness, spreading by person to person contact via droplets. Fulminant infection may develop leading to severe pneumonia, renal failure and even death. The existence of this pandemic makes surgical management a challenge as it risks exposing the surgical team to known, suspected or asymptomatic Covid-19 cases. Surgical management has to be limited to cases, that cannot be otherwise conserved or postponed, to limit unnecessary exposure of both the surgical team and the patient to Coronavirus. It also allows diversion of members of the team towards management of Covid-19 pandemic associated increased admissions. \hyperref[b13]{12} . Laproscopic surgery involves creation of pneumoperitoneum which increases risk of aerosol exposure to the operating team. Electrical equipment and harmonic scalpels used in laproscopic surgery generate surgical smoke that cannot effectively deactive cellular component of the virus. Level 3 protection is mandatory for the operating team. Closed smoke evacuation/ filteration systems with ULPA (Ultra Low Particulate Air Filteration) capacity should be used during MIS, minimal use of energy sources, separate cleaning of surgical equipment need to be exercised. \hyperref[b14]{13} All patients to be considered as COVID-19 positive unless proven otherwise, and operated with proper precautions that need to be exercised for positive patients. Patients have to be explained the risk of aquiring covid-19 during procedure and hospitalisation.\par
IV. 
\section[{Conclusion}]{Conclusion}\par
Acute appendicitis, with prevalent Covid-19 and its associated morbidity to the patient undergoing surgical procedures and risk to the operating team can be managed conservatively, even with a higher Alvarado Score on presentation, unless complicated with fecolith, appendicular perforation or abscess or failure to resolve after conservative management. Conservative management decreases the burden on the already overwhelmed hospital resources, medical team due to Covid-19 and limits unnecessary exposure for both patient and the operating team.\begin{figure}[htbp]
\noindent\textbf{} \par 
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\tabcellsep \multicolumn{5}{l}{Management of Acute Appendicitis in Covid Pandemic-A Prospective Study of 25 Cases}\\
\tabcellsep \multicolumn{4}{l}{Out of the six operated patients, indications for surgery were as follows}\\
\tabcellsep \multicolumn{2}{l}{GROUP A (Conservative Management)-19 patients Patient (Serial number )}\tabcellsep \tabcellsep \multicolumn{2}{l}{Indication}\\
\tabcellsep \multicolumn{2}{l}{Alvarado Score 1 1-4 2 5-6 7-10 3}\tabcellsep \multicolumn{3}{l}{Guarding on presentation, elevated leucocyte count Number of Patients (n=19) Tender RIF, Elevated leucocyte count, Appendicular 0 perforation on USG 2 (11\%) Tender RIF, Elevated Leucocyte count Appendicular 17 (89\%) perforation on USG}\\
\tabcellsep \multicolumn{2}{l}{GROUP B (Operative Management )-6 patients 4}\tabcellsep \multicolumn{3}{l}{Worsening of symptoms, abdominal examination}\\
\tabcellsep \multicolumn{2}{l}{Alvarado Score 1-4 5 5-6 6 7-10}\tabcellsep \multicolumn{3}{l}{findings and leucocytosis Number of Patients (n=6) Guarding on presentation, elevated leucocyte count 0 Worsening of symptoms, abdominal examination 2 (33.33\%) 4 (66.66\% ) findings and leucocytosis}\\
8 Year 2020 Volume XX Issue II Version I Year 2020 Volume XX Issue II Version I\tabcellsep \multicolumn{5}{l}{Antibiotics given: Antibiotics were given depending on Leucocyte count of the patients were compared, 14 patients had leucocytosis (>11,000/L), wheras 11 patients had Cefoperazone with sulbactam was given to 14 patients, leucocytes within the normal range. USG diameter of appendix Appendix diameter clinical severity and leucocytosis. Metronidazole was given to all patients for anerobic coverage. whereas ceftriazone was given to seven patients and piperacillin tazobactam was given to four patients. Duration of hospital stay in group A vs B Number of Patients (n=25) </= 6mm Group Mean Duration of Hospital Stay Group A (Conserved) 4.47 days 3 (12\%) >6mm 18 (72\%) USG evidence of appendicular abscess/ fecolith/ perforation/ appendicular mass USG Findings Number of patients Appendicular abscess/ perforation 2 (8\%) Fecolith 0 Appendicular mass 2 (8\%) Group B (Operated) 6.8 days}\tabcellsep Year 2020 9 Volume XX Issue II Version I\\
D D D D ) D D D D ) I\tabcellsep Age distribution was as follows,\tabcellsep \tabcellsep 8\%\tabcellsep 12\%\tabcellsep D D D D ) I\\
Global Journal of Global Journal of Medical Research Medical Research ( (\tabcellsep \multicolumn{5}{l}{Age distribution ( in years ) 15-25 26-35 36-45 46-55 >55 Comorbidities-One patient was diabetic and hypothyroid and others had no comorbidities. Number of patients (n=24) 6 (24\%) 3 (12\%) 0 0 Duration of symptoms ( in hours ) Number of patients (n=24) <24h 2 (8\%) 24-48h 10 (40\% ) 48-72h 6 (24\%) >72h 3 (12\%) diarrhoea, urinary complaints. <6 mm appendix >6 mm appendix Appendicular mass Appendicular abscess/ Perforation Presenting symptoms were compared, including, Pain in right iliac fossa, nausea/vomiting, anorexia, fever, 72\% Duration of pain in right iliac fossa was compared, 16 (64\%) 8\%}\tabcellsep Global Journal of Medical Research (\\
\tabcellsep \multicolumn{5}{l}{Number of patients Figure 1: USG FINDINGS Presenting complaint (n=24) Pain in right iliac fossa 25 Number of patients operated verus conserved}\\
\tabcellsep \multicolumn{3}{l}{Nausea/ Vomiting Treatment}\tabcellsep \multicolumn{2}{l}{10 Number of Patients (n=24)}\\
\tabcellsep Conservative\tabcellsep Fever\tabcellsep \tabcellsep 1\tabcellsep 19 (76\%)\\
\tabcellsep Operative\tabcellsep Diarrhoea\tabcellsep \tabcellsep 0\tabcellsep 6 (24\%)\\
\tabcellsep \multicolumn{3}{l}{Urinary Complaints}\tabcellsep 0\\
\tabcellsep © 2020 Global Journals\tabcellsep \tabcellsep \tabcellsep \end{longtable} \par
 
\caption{\label{tab_0}}\end{figure}
 			\footnote{© 2020 Global Journals} 			\footnote{© 2020 Global Journals Management of Acute Appendicitis in Covid Pandemic-A Prospective Study of 25 Cases} 		 		\backmatter  			  				\begin{bibitemlist}{1}
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\end{document}
