CC BY
85
REVIEWS
CURRENT STAT OF ACUTE APPEN
UDC 616.346.2-002.1-07 Received 1.02.2012
R.R. Kasimov, Chiev Resident1;
A.S. Mukhin, D.Med.Sc., Professor
of the Department of Surgery, the Faculty of Doctors’ Advanced Training1
1Military Clinical Hospital No.1586^Branch No.5, Izhorskaya St., 25, Nizhny Novgorod, Russian Federation, 603105;
2Nizhny Novgorod State Medical-Academy, Minin and Pozharsky Square, 10/1, Nizhny Novgorod,
Russian Federation, 603000
The advantages and disadvantages of current techniques of clinical laboratory and instrumental study in acute appendicitis have been ....jd^ed-'The-re'have been-^hown prospective directions in the development of diagnostic methods. The possibilities of integral diagnosis of cute appendicitis have been presented in detail.
Keywords^-acute appendicitis; integral diagnosis of appendicitis; “negative” appendectomy; acute appendicitis diagnostic score.
The incidence of acute appendicitis (AA) in the total population accounts for to 0.1—0.6% with a steady downward trend [1-3]. The improvement of the diagnostic methods makes a great contribution to it. The diagnostic errors result in “unreasonable” operations as well as in delayed surgical care, their frequency being 2.3-34.5% [3-9]. The interest in the preoperative diagnosis of AA forms does not wane. Videolaparoscopy is a sufficiently effective technique; however, it is an invasive procedure. Laparoscopy under local anesthesia does not provide enough information. Current methods of diagnosis are based on costly forms of instrumental and laboratory studies, often requiring the involvement of top experts and specific equipment. The present review was aimed at reflecting up-to-date trends in the development of AA diagnosis, assess the existing methods in terms of efficiency and optimality.
Clinical and laboratory study
The AA clinical diagnosis is traditionally primary [5, 1013]. However, the true efficiency of many of the ‘specific' appendicular symptoms is not adequate [14, 15]. These routine clinical laboratory tests do not have anything specifically associated with AA. The known techniques of differential laboratory diagnosis based on determining a patient's degree of intoxication at various indices (Ya.Ya. Kalf-Kalif's leukocyte index of intoxication (1941), V.A Shalygina's index of erythrocyte aggregation (1997), T.Sh. Khabirova's an index of neutrophils response (2000) provide little information. There are some reports that a leukocyte count is also of no practical significance in AA diagnosis and, moreover, does not allow to suggest its form [16].
C-reactive protein (CRP) study in the range of “subclinical” values, i.e. up to 10 mg/L, is of a particular interest. CRP level of over 5 mg/L may be the evidence of destructive appendicitis and is an indication for surgical
treatment 16-19]. However, various aspects unrelated directly to acute surgical pathology can lead to false-positive results. The rate of a CRP increase (CRPv) distinguishes a bacterial inflammation from a non-bacterial one. Thus, CRPv over 1.08 mg/L/h indicates a bacterial inflammatory reaction. The sensitivity, specificity and accuracy of the method are 75.0-98.0%, 66.0-87.0%, 72.0-96.0%,
respectively. A comprehensive study such as a “triple test” (CRP, leukocyte count and neutrophil count) increases the sensitivity (94.4%) and prognostic value (98.7%) of the method [20]. A semi-quantitative method for determining CRP is cheap and fast to be applied but less accurate in comparison with a quantitative one.
Current immunochemical techniques for AA diagnosis have not been widely used so far, remaining theoretical and applied methods in some clinics. They are as follows: a comprehensive immunological study [21,22] determining the level of metal-proteins in biological fluids [23], the use of a polymerase chain reaction in order to indicate and identify viruses [24], calprotectin tests (S100A8/A9) [25, 26], E-selectin [27], serum YKL-40 [28], D-lactate [29], 5-hydroxyindole acetic acid level [30] and urine alpha-2-glycoprotein [21]. The common shortcomings of these methods are high costs and long-term performance of immunochemical tests.
AA integral Diagnosis
Since the end of the past century the Alvarado scoring system used for AA diagnosis has been widespread worldwide [31]. It is based on the determining of an index of acute appendicitis (IAA) by summing up the points of 8 signs: migration of pain, anorexia, vomiting (nausea), tenderness in the right iliac fossa, positive Shotkin-Blumberg's symptom, elevated temperature, leukocytosis, left shift in leukocyte count. The diagnostic accuracy is 82.7-90.0%, and “negative” appendectomy while using
For contacts: Kasimov Rustam Rifcatovich, phone: +7 920-035-06-19; e-mail: [email protected]
112 СТМ J 2013 - vol. 5, No.4 R.R. Kasimov, A.S. Mukhin
REVIEWS
Table 1
Mathematical differential diagnostic table
Difference in axillary Difference in axillary
and rectal temperature and rectal temperature
of less than 0.5°С of more than 0.5°С
Symptom Onset of pain
not in the right in the right not in the right in the right
iliac region iliac region iliac region iliac region
Yes No Yes No Yes No Yes No
No similar episodes in the past 8 -1 6 -3 9 0 7 -2
Nausea, vomiting 12 -3 10 -5 13 -2 11 -4
Muscle tension in the right iliac area 9 3 7 1 10 4 8 2
Shotkin’s sign 12 3 10 1 13 4 11 2
Leukocytosis 9 -3 7 -5 10 -2 8 -4
LII more than 3,5 13 -3 11 -5 14 -2 12 -4
Body temperature above 37,0°С 11 5 9 3 12 6 10 4
Tachycardia — 90 and above 5 -3 3 -5 6 -2 4 -4
Rovsing’s sign 5 1 3 -1 6 2 4 0
Dry or coated tongue 3 0 1 0 4 0 2 0
Hereinafter: LII — leukocyte index of intoxication.
it amounts to 14.3-17.5% [11, 31]. The score's being based exclusively on clinical and laboratory findings is its shortcoming. IAA for doubtful AA often shows the values of “AA is unlikely”. The sensitivity of the score of 5-7 (“AA is possible”) is only 58-88%. The AA diagnostic accuracy goes up to 92-98% when performing computed tomography (CT) with the score of 7-8 [32-34]. Modifications of the score including additional research methods are suggested [2, 11, 35].
The Alvarado-modified diagnostic scoring system for AA was developed and implemented into clinical practice in the I.M. Sechenov Moscow Medical Academy (Russia) [2]. A key point of the method is to perform ultrasound imaging of the vermiform appendix at the IAA values corresponding to “AA is probable”. The sensitivity, specificity, accuracy, prognostic value of positive and negative results are 87.0, 96.7, 94.0 and 89.2%, respectively. “In'ffective” appendectomies were performed in 12.3% of cases. A method for AA diagnosis in children was developed and implemented. It is based on determining a clinical index by summing up the scores of 6 symptoms: nausea (2 points), specificity of the local pain in the right lower abdominal quadrant (2 points), migration of pain (1 point), walking with difficulty (1 point), a peritoneal irritation symptom or pain at percussion (2 points), neutrophil count of over 6,75-103/ml (6 points). Patients with an index lower than 5 are unlikely to develop AA. The sensitivity of the score is 96.3% [36].
An original score for AA diagnosis was developed in the RIPAS Hospital in Brunei [9]. It takes into account a patient's sex, age, duration of the disease, clinical and laboratory signs of AA (pain in the right iliac area, migration of pain, nausea, vomiting, local defense, peritoneal signs, Rovsing's sign, fever, leukocytosis, changes in the urine test). The sensitivity, specificity, and accuracy are 97.0, 82.0 and 92.0%, respectively. “Unreasonable” appendectomies are
performed in 19.4% of cases, and the predicted rate of “negative” appendectomy is 13.5%.
The key points of diagnostic research in the mathematical differential diagnostic table of AA (Table 1) developed by Russian scientists (Saratov) [37] are the difference in axillary and rectal temperature and the anatomical abdominal area of the onset of pain. According to the authors, the method improves AA diagnosis and enables to predict a histological form of the vermiform appendix with 95-96% probability. The disadvantages of this method are its being unhandy and labor-consuming. The total score of 41 or more indicates destructive appendicitis. With a score of less than 35 a follow-up and further observation to clarify the diagnosis is indicated. With a score of 35-41 laparoscopy is indicated.
We have developed a differential diagnostic and treatment algorithm. Its main link is the determination of the IAA according to a score (See Table 2) in which the score values of the signs depending on their “weight” significance
Table 2
The score of acute appendicitis diagnosis
Sign Score
Leukocytosis (leukocyte count over 8.8109/L) 1
LII (by Kalf-Kalif) over 1.6 2
CRP level of ^5 mg/L 2
Body temperature of ^37.0°С 10
Kocher-Volkovich’s symptom 10
Shotkin’s symptom 2
Local guarding 7
Presence of two or more of appendicular symptoms 7
Current State of Acute Appendicitis Diagnosis СТМ J 2013 — vol. 5, No.4 113
REVIEWS
are calculated mathematically and rounded to the nearest integer.
The interpretation of the results is as follows: “AA is improbable”, if IAA is up to 16 points and including; “AA is probable”, if IAA ranges from 17 to 29 points; “AA patient” if IAA is 30 points and more. Characteristics of the score: sensitivity is 95.0%, specificity is 100%, overall accuracy is 97.5%, false-negative response is 5.0%, false-positive response is 0%, positive predictive value is 95.2%. The algorithm is valid for the facilities with a various therapeutic and diagnostic potential. In case of IAA being “AA is probable”, mandatory hospitalization with active observation and ultrasound scanning of the appendix is indicated. If the sonographic signs of AA are missing or ultrasound scanning of the appendix is not possible, dynamic observation with the determination of IAA repeated every 2 hours must be provided. Video laparoscopy is indicated in case of IAA rise or persisting doubts about the diagnosis. If IAA value is “a patient has AA”, a diagnostic laparoscopy transferring into a treatment one is advisable to confirm the diagnosis.
instrumental study
Currently, the usefulness of routine ultrasound imaging of the vermiform appendix is being debated [1,5, 7, 8, 38, 39]. The undeniable advantages of the method are its non-invasiveness, availability, a possibility to perform a study dynamically, absence of radiation exposure to the patient and the staff. The sensitivity of the method is 80.7-95.6%, specificity is 47.0-99.1%, the overall accuracy is 71.098.0%. The information value increases with color Doppler
and power mapping of the blood flow. At the same time, at the positive ultrasound decision, the unchanged appendix is removed in 6.7% of cases [1]. This method is the most informative in complicated AA [1, 5, 38-41]. 3.5-10 MHz linear and convex probes are usually used to perform the study. The sonographic sign of AA is a blind-ended tubular structure at the point of maximum tenderness with the outer diameter of 6 mm which is aperistaltic and can not be compressed, with wall hyperemia in the initial stages of inflammation at the color Doppler study, the wall being 2 mm thick, and often contains fecal bolus. At cross-scanning the tubular structure resembles a “target”, “cockade”, the wall thickness of the stromal component of the appendix being 5 mm or more (See the figure). The ultrastructure of the appendix at sonography is differentiated better than at CT scanning, which enables to predict the AA form better preoperatively [10]. The main disadvantage of the method is that the results depend considerably on the expert’s qualifications.
The X-ray method of testing in AA has supporting significance. Indirect signs of appendicitis at plain abdominal radiography are observed in less than half number of cases [7]. These include: appendicolitis shadows observed in 20-33.0% of children and in 10.0% of adults, isolated stretching of the terminal ileum loops with fluid levels, but gas in the appendix may be present in healthy subjects, too. Irrigoscopy is more informative with appendicular infiltrate, colonoscopic appendicography presents interest in the diagnosis of chronic appendicitis.
The CT accuracy in AA diagnosis is of 94.0-100% [33, 36-38], and in that event “negative” appendectomies
Patient Zh., 21, has undergone a cross scanning of the vermiform appendix. He shows “a target” symptom. The anterior-posterior diameter of the part of the appendix is 0.72 cm, its width is 1.38 cm and wall thickness — 0.31 cm. The accumulation of the fluid is observed around the appendix (from the personal files)
//МШШШШМШШШШШШШШМШММЖШШМШШШЖШШМЖШММЖШШШ'
114 СТМ J 2013 — vol. 5, No.4 R.R. Kasimov, A.S. Mukhin
REVIEWS
make up 3-8.0% [32, 40-43]. The appropriateness of this study in complicated AA and doubtful cases is practically not disputable, and the usefulness of routine CT is actively discussed. It is believed that this method does not reliably reduce the rate of “undue” appendectomy [8, 33, 40-41].
Currently, hardware-based methods based on radiophysical and electric effects in the inflamed tissues are investigated. Trans-resonant functional topography, deep microwave radiotermography, electromyography, the mathematical analysis of heart rate variations provide indirect findings of the appendix involvement into the pathological process. [21,44, 45].
The issues of AA laparoscopic diagnosis are substantially represented in modern literature. The accuracy of the method is quite high, it is 92.0-95.8%, sensitivity is 92.098.7%, specificity is 91.1% [1, 12]. Laparoscopy is the final step in AA diagnosis, when all the non-invasive methods have been used, but the diagnosis yet being doubtful. An advantage is its easy transformation into a therapeutic surgical aid [6]. It is videolaparoscopy that allows providing a comprehensive revision of the abdominal cavity [8, 12, 46]. Diagnostic errors occur in 1.7-3.0% of cases, and the study gives little information in 6.6-8.5% of cases because of the anatomical features [5, 7, 42]. In case of a difficulty in catarrhal appendicitis verification dynamic laparoscopy is required. Video laparoscopy allowed reducing the rate of diagnostic errors significantly in most clinics [8, 12] and catarrhal AA was excluded in some others [47-49].
The use of diagnostic laparoscopy enables to reduce the rate of appendectomies for acute appendicitis, which leads to the reduction of suppurative septic complications, as well as to a marked economic effect.
Thus, the following main provisions can characterize the current state of AA diagnosis: 1) the diagnostic criteria for AA are polymorphic, no specific sign has been found, 2) there is a steady trend to a less aggressive surgical approach due to the introduction of additional research techniques; 3) the economic aspects of modern medicine leave the most promising methods for AA diagnosis within the scope of theory and application use.
At the present time the radiologic studies are undoubtedly a priority, being highly informative and non-invasive. Laparoscopy reduced the number of diagnostic errors, though has not excluded them completely. We must not forget that an adequate diagnosis in this method is only achieved with the use of anesthesia and endovideosurgical techniques. With a low therapeutic diagnostic potential of a medical facility the integrated approach can optimize AA diagnosis.
Study Funding and Conflict of interest. This study was not supported by any financial sources and there is no topic specific conflict of interest related to the authors of this study.
References
1. Endovideoskopicheskieirentgenokhirurgicheskievmeshatelstva na organakh zhivota, grudi i zabryushinnogo prostranstva. Ch. 2 [Endovideoscopic and X-ray surgeries on abdominal, thoracic and retroperitoneal organs. Part 2]. Pod red. Borisova A.E. [Borisov A.E. (editor)]. Saint Petersburg: Skifiya-print; 2006; 400 p.
2. Natroshvili A.G., Shulutko A.M., Nasirov F.N. Rezul'taty
primeneniya modifitsirovannoy diagnosticheskoy shkaly u bol'nykh ostrym appenditsitom [The results of using a modified diagnostic scale in patients with acute appendicitis]. Khirurgiya. Zhurnalim. N.I. Pirogova — Surgery. Journal named after N.I. Pirogov 2010; 8: 24-27.
3. Pryakhin A.N., Gazizullin R.Z. Laparoskopicheskaya appendektomiya [Laparoscopic appendectomy]. Chelyabinsk; 2005; 75 p.
4. Dolgushkin A.N., Zhuravlev P.A. Laparoskopiya kak metod vybora v diagnostike i lechenii ostrogo appenditsita [Laparoscopy as a method of choice in the diagnosis and treatment acute appendicitis]. Al’manakh klinicheskoy meditsiny — Almanac of Clinical Medicine 2007; 16: 61-62.
5. Kriger A.G., Fedorov A.V., Voskresenskiy P.K., Dronov A.F. Ostryy appenditsit [Acute appendicitis]. Moscow: Medpraktika-M; 2002; 244 p.
6. Efimenko N.A., Chursin V.V., Stepnov A.A., et al. Lechebnaya i diagnosticheskaya laparoskopiya pri appenditsite [Therapeutic and diagnostic laparoscopy in appendicitis]. Voenno-meditsinskiy zhurnal — Military Medical Journal 2007; 8: 19-23.
7. Sinenchenko G.I., Kurygin A.A., Bagnenko S.F. Khirurgiya ostrogo zhivota [Surgery o acute abdomen]. Saint Petersburg: Elbi-SPb; 2007; 512 p.
8. Yartsev P.A., Ermolov A.S., Pakhomova G.V. Laparoskopiya v diagnostike i lechenii ostrogo appenditsita [Laparoscopy in diagnostics and treatment of acute appendicitis]. Khirurgiya. Zhurnal im. N.I. Pirogova — Surgery. Journal named after N.I. Pirogov 2010; 4: 21-25.
9. Chong Chee Fui, Thien Amy, Ahamed Mackie Ahamed Jiffri, et al. Evaluation of the RIPASA Score: a new scoring system for the diagnosis of acute appendicitis. Brunei Int Med J 2010; 6(1): 21-27.
10. Hiroshi Ishikaw. Diagnosis and treatment of acute appendicitis. JMAJ 2003; 46(5): 217-221.
11. Malik A.A., Wani N.A. Continuing diagnostic challenge of acute appendicitis-evaluation through modified Alvarado score. Aust N Z J Surg 1998; 68: 504-505.
12. Mishra R.K., Hanna G.B., Cuschieri A. Laparoscopic versus open appendectomy for the treatment of acute appendicitis. World Journal of Laparoscopic Surgery 2008 January-April; 1(1): 19-28.
13. Tan L.T.H., Ong K.L. Clinical and ultrasonographic diagnosis of acute appendicitis. Hong Kong Journal of Emergency Medicine 2004; 11(2): 110-116.
14. Evtikhov R.M., Shulutko A.M., Zhuravlev V.A., et al. Khirurgicheskie bolezni [Surgical diseases]. Ivanovo: MIK; 1998; 333 p.
15. Rotkov I.L. Diagnosticheskie i takticheskie oshibki pri ostrom appenditsite [Diagnostic and tactical mistakes in acute appendicitis]. Moscow: Meditsina; 1980; 208 p.
16. Shozo Y., Katsunari T., Tsukasa H., et al. C-reactive protein is an independent surgical indication marker for appendicitis: a retrospective study. World Journal of Emergency Surgery 2009; 4: 36.
17. Titov V.N. Diagnosticheskoe znachenie povyshenie urovnya S-reaktivnogo belka “v klinicheskom” i “subklinicheskom” intervalakh [Diagnostic significance of C-reactive protein level increase in “clinical” and “subclinical” intervals]. Klin Lab Diagnostika — Clinical Laboratory Diagnosis 2004; 6: 3-10.
18. Agrawal C.S., Adhikari S., Kumar M. Role of serum C-reactive protein and leukocyte count in the diagnosis of acute appendicitis in Nepalese population. Nepal Med Coll J 2008; 10(1): 11-15.
19. Hart W.R. C-reactive protein: the best laboratory indicator available for monitoring disease activity. Cleve Clin J Med 1989; 56: 126-130.
20. Shafi S.M., Afsheen M., Reshi F.A. Total leucocyte count, C-reactive protein and neutrophil count: diagnostic aid in acute appendicitis. Saudi J Gastroenterol 2009; 15: 117-120.
21. Fomin S.A. Diagnostika i lechenie ostrogo appenditsita [Diagnosis and treatment of acute appendicitis]. Yaroslavl; 2010; 123 p.
22. Lisunov A.Yu. Optimizatsiya diagnostiki i lecheniya razlichnykh form appenditsita. Avtoref. dis. ... kand. med. nauk [Optimization of diagnosis and treatment of various forms of appendicitis. Abstract for Dissertation for the degree of Candidate of Medical Science]. Saratov; 2008.
Current State of Acute Appendicitis Diagnosis СТМ J 2013 — vol. 5, No.4 115
REVIEWS
23. Kichibekov E.A. Zhelezosoderzhashchie belki kak markery destruktsii pri ostrom appenditsite [Iron-containing proteins as destruction markers in acute appendicitis]. Voenno-meditsinskiy zhurnal — Military Medical Journal 2010; 8: 50-51.
24. Tashtemirova O.G., Manekenova K.B., Aref'eva Zh.A. Sposob identifi-katsii virusnoy infektsii v bioptatakh cherveobraznogo otrostka [A method of viral infection identification in vermix bioptates]. Nizegor Med Z — Nizhny Novgorod Medical Journal 2005; 4: 120-122.
25. Mills A.M., Huckins D.S., Kwok H., et al. Diagnostic characteristics of s100A8/A9 in a multicenter study of patients with acute right lower quadrant abdominal pain. Acad Emerg Med 2012 Jan; 19(1):48-55.
26. Thuijls G., Derikx J.P., Prakken F.J., et al. A pilot study on potential new plasma markers for diagnosis of acute appendicitis. Am J Emerg Med 2011 Mar; 29(3): 256-260.
27. Brochhausen C., Bittinger F., Schmitt V.H., et al. Expression of E-selectin and vascular cell adhesion molecule-1 in so-called ‘negative' appendices: first results to support the pathological diagnosis in borderline cases. Eur Surg Res 2010; 45(3-4): 350-355.
28. Koc M., Zulfikaroglu B., Kemal Isman F., et al. Serum YKL-40 levels in acute appendicitis. Bratisl Lek Listy 2010; 111(12): 656-658.
29. Filiz A.I., Aladag H., Akin M.L., et al. The role of D-lactate in differential diagnosis of acute appendicitis. J Invest Surg 2010 Aug; 23(4): 218-223.
30. Mentes O., Eryilmaz M., Harlak A., et al. The importance of urine 5-hydroxyindoleacetic acid levels in the early diagnosis of acute appendicitis. Am J Emerg Med 2009 May; 27(4): 409-412.
31. Alvarado A. A practical score for the early diagnosis of acute appendicitis. Ann Emerg Med 1986 May; 15(5): 557-564.
32. Paulson E.K., Kalady M.F., Pappas T.N. Suspected Appendicitis. The New England Journal of Medicine 2003 Jan; 16: 236-242.
33. Rezak A., Abbas H.M.A., Ajemian M.S. Decreased use of computed tomography with a modified clinical scoring system in diagnosis of pediatric acute appendicitis. Arch Surg 2011; 146(1): 64-67.
34. Tamburrini S., Brunetti A., Brown M. Acute appendicitis: diagnostic value of nonenhanced CT with selective use of contrast in routine clinical settings. Eur Radiol 2007; 17: 2055-2061.
35. McKay R., Shepherd J. The use of the clinical scoring system by Alvarado in the decision to perform computed tomography for acute appendicitis ED. Am J Emerg Med 2007 Jun; 25(5): 489-493.
36. Kharbanda Anupam B., Taylor George A., Fishman Steven J., et al. A clinical decision rule to identify children at low risk for appendicitis. Pediatrics 2005; 116: 709.
37. Slesarenko C.S., Lisunov A.Yu. Osobennosti khirurgicheskoy taktiki i lecheniya ostrogo appenditsita na sovremennom etape [The characteristics of surgical approach and treatment of acute appendicitis at the present stage]. Saratovskiy nauchno-
qeditsinskiy zhurnal — Saratov Research Medical Journal 2008; L1-118.
ya Yu.V., Izrailov R.E., Lemeshko Z.A. Ul'trazvukovoe nostike i lechenii ostrogo appenditsita [Ultrasound
investigation in the diagnosis and treatment of acute appendicitis]. Moscow: GEOTAR-Media; 2009; 72 p.
39. Shulutko A.M., Nasirov F.N., Natroshvili A.G. Nuzhno li ul'trazvukovoe issledovanie v diagnostike ostrogo appenditsita? [Is ultrasound investigation needed in the diagnosis of acute appendicitis?]. Meditsinskaya vizualizatsiya — Medical Imaging 2001; 3: 52-56.
40. Ultrasound in surgical practice: basic principles and clinical applications. Jay K. Harness J.K., Wisher D.V. (editors). New York: Wiley-Liss, 2001.529 p.
41. Soda K., Nemoto K., Yoshizawa S. Detection of pinpoint tenderness on the appendix under ultrasonography is useful to confirm acute appendicitis. Arch Surg 2001; 136: 1136-1140.
42. Meeks D.W., Kao L.S. Controversies in appendicitis. Surgical Infections 2008; 9(6): 553-558.
43. Mittal V., Goliath J., Sabir M. Advantages of focused helical computed tomographic scanning with rectal contrast only vs triple contrast in the diagnosis of clinically uncertain acute appendicitis. Arch Surg 2004; 139: 495-500.
44. Gromov M.S., Terekhov I.V. Ispol'zovanie TRF-topografii s tselyu op-timizatsii diagnosticheskoy taktiki u patsientov s podozreniem na ostruyu vospalitel'nuyu patologiyu organov bryushnoy polosti [The use of PDGF-topography in order to optimize diagnostic management in patients with suspected acute inflammatory abdominal pathology]. Vestnik novykh meditsinskikh tekhnologiy — Vestnik of New Medical Technologies 2008; 2: 89-91.
45. Chernykh A.V., Shabalin R.V. Primenenie analiza sostoyaniy vege-tativnoy nervnoy sistemy v diagnostike, prognozirovanii techeniya i opredeleniya taktiki lecheniya ostrogo appenditsita [The application of the analysis of autonomic nervous system state in diagnosis, clinical course prognosis, and determination of management of acute appendicitis]. Vestnik eksperimentalnoy i klinicheskoy khirurgii — Vestnik of Experimental and Clinical Surgery 2009; 3(2): 184-192.
46. Roshal' L.M., Karaseva O.V. K voprosu o klassifikatsii ostrogo ap-penditsita i ego oslozhneniy [To the study of classification of acute appendicitis and its complications]. Rossiyskiy pediatricheskiy zhurnal — Russian Pediatric Journal 2006; 2: 34-38.
47. Ermolov A.S. Sostoyanie ekstrennoy khirurgicheskoy pomoshchi pri ost-rykh zabolevaniyakh organov bryushnoy polosti v Moskve za 2001-2005 gg. i v 2005 g. [The state of urgent surgical service in acute abdominal diseases in Moscow over the period of 2001-2005 and in 2005]. Endoskopicheskaya khirurgiya — Endoscopic Surgery 2006; 6: 49-66.
48. Dolgushkin A.N., Zhuravlev P.A. Laparoskopiya kak metod vybora v diagnostike i lechenii ostrogo appenditsita [Laparoscopy as a method of choice in the diagnosis and treatment of acute appendicitis]. Al’manakh klinicheskoy meditsiny — Almanac of Clinical Medicine 2007; 16: 61-62.
49. Letnikov B.A., Chebotarev V.D., Matveev A.B. Sovremennye tendentsii lecheniya ostrogo appenditsita v usloviyakh khirurgicheskogo statsionara TsRB [Current trends in acute appendicitis treatment in surgical hospital of central distric hospital]. Endosk Hir — Endoscopic Surgery 2009; 1: 127-128.
уттттт^тттттттттттттттттттттттттттттттттттттіттттт'
116 СТМ J 2013 - vol. 5, No.4 R.R. Kasimov, A.S. Mukhin
