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",isbn:"978-1-83968-924-6",printIsbn:"978-1-83968-923-9",pdfIsbn:"978-1-83968-925-3",doi:null,price:0,priceEur:0,priceUsd:0,slug:null,numberOfPages:0,isOpenForSubmission:!1,hash:"ea4ec0d6ee01b88e264178886e3210ed",bookSignature:"Dr. Hiran Wimal Amarasekera",publishedDate:null,coverURL:"https://cdn.intechopen.com/books/images_new/9500.jpg",keywords:"Bone Tumors, Oncology, Childhood Tumors, Cancer, Risk Factors, Modern Management, Benign Lesions, Tumor-Like Conditions, Immunology, Histochemistry, Cell Oncology, Tumor Markers",numberOfDownloads:389,numberOfWosCitations:0,numberOfCrossrefCitations:1,numberOfDimensionsCitations:1,numberOfTotalCitations:2,isAvailableForWebshopOrdering:!0,dateEndFirstStepPublish:"September 28th 2020",dateEndSecondStepPublish:"October 26th 2020",dateEndThirdStepPublish:"December 25th 2020",dateEndFourthStepPublish:"March 15th 2021",dateEndFifthStepPublish:"May 14th 2021",remainingDaysToSecondStep:"4 months",secondStepPassed:!0,currentStepOfPublishingProcess:4,editedByType:null,kuFlag:!1,biosketch:"Consultant Orthopaedic Surgeon from Sri Lanka currently working in University Hospitals of Coventry and Warwickshire, UK, trained at the National Hospital of Sri Lanka, at the Oldchurch Hospital in Essex UK and The Avenue Hospital Melbourne, Australia and University Hospitals of Coventry and Warwickshire, UK, obtained the FRCS from Royal College of Surgeons of Edinburgh, Scotland.",coeditorOneBiosketch:null,coeditorTwoBiosketch:null,coeditorThreeBiosketch:null,coeditorFourBiosketch:null,coeditorFiveBiosketch:null,editors:[{id:"67634",title:"Dr.",name:"Hiran",middleName:"Wimal",surname:"Amarasekera",slug:"hiran-amarasekera",fullName:"Hiran Amarasekera",profilePictureURL:"https://mts.intechopen.com/storage/users/67634/images/system/67634.jpg",biography:"Hiran Amarasekera is a Consultant Orthopaedic Surgeon from Sri Lanka currently working in University Hospitals of Coventry and Warwickshire, the UK as a hip preservation fellow. \r\nHis special interests include young adult hip and knee problems, sports injuries, Hip and knee arthroplasty, and complex arthroscopic procedures. \r\nHe completed the MBBS from Kasturba medical college Manipal, India and did his postgraduate in Trauma and Orthopaedics at the Post-graduate Institute of the Medicine University of Colombo obtained the MS. \r\nHe was initially trained at the National Hospital of Sri Lanka and then completed the further training at the Oldchurch Hospital in Essex UK and The Avenue Hospital Melbourne, Australia and University Hospitals of Coventry and Warwickshire, UK.\r\nHe obtained the FRCS from Royal College of Surgeons of Edinburgh in 2003 and was elected a fellow of Sri Lanka College of surgeons (FCSSL) 2012. \r\nHe has a keen interest in academia and research. 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Venkateswarlu",coverURL:"https://cdn.intechopen.com/books/images_new/371.jpg",editedByType:"Edited by",editors:[{id:"58592",title:"Dr.",name:"Arun",surname:"Shanker",slug:"arun-shanker",fullName:"Arun Shanker"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"878",title:"Phytochemicals",subtitle:"A Global Perspective of Their Role in Nutrition and Health",isOpenForSubmission:!1,hash:"ec77671f63975ef2d16192897deb6835",slug:"phytochemicals-a-global-perspective-of-their-role-in-nutrition-and-health",bookSignature:"Venketeshwer Rao",coverURL:"https://cdn.intechopen.com/books/images_new/878.jpg",editedByType:"Edited by",editors:[{id:"82663",title:"Dr.",name:"Venketeshwer",surname:"Rao",slug:"venketeshwer-rao",fullName:"Venketeshwer Rao"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}}]},chapter:{item:{type:"chapter",id:"39352",title:"Using a Low Complexity Numeric Routine for Solving Electromagnetic Transient Simulations",doi:"10.5772/48507",slug:"using-a-low-complexity-numeric-routine-for-solving-electromagnetic-transient-simulations",body:'Different methods can be applied to accomplish the analysis of transmission lines. Many mathematical tools can be used, the main tools used are: circuits analysis with the use of Laplace or Fourier Transform, State Variables and Differential Equations. These tools can be included in a numeric routine in order to obtain voltage and current values in simulation of electromagnetic transients, at any point of the circuit.
The EMTP (ElectroMagnetic Transient Program) [1] is the main kind of this software. The prototype was developed in 60’s by professionals of power system area led by Dr. Hermann Dommel (University of British Columbia, in Vancouver, B.C., Canada), and Dr. Scott Meyer (Bonneville Power Administration in Portland, Oregon, U.S.A.). Currently, EMTP is the basis of electromagnetic transients simulations in power systems.
With EMTP type programs, the following analysis can be done: simulation of switching and lightning surges, transient and temporary overvoltage, electrical machines, resonance phenomena, harmonics, power quality and power electronics applications. The most known programs of EMTP type are:
MicroTran Power Systems Analysis of the University of British Columbia, Vancouver, Canada, founded in 1987 by: Hermann W. Dommel, Jose R. Marti (University of British Columbia), and Luis Marti (University of Western Ontario, Hydro One Networks Inc.).
PSCAD®, also known as PSCAD®/EMTDC™ of Manitoba HVDC Research Centre. Commercially available since 1993, PSCAD® is the result of continuous research and development since 1988.
ATP has been continuously developed through international contributions by Drs. W. Scott Meyer and Tsu-huei Liu, the co-Chairmen of the Canadian/American EMTP User Group. The birth of ATP dates to early in 1984. For the free software, however there are some rules for using it.
This kind of program, in general, doesn’t present an easy interface where data can be included [5]. Thus, many times, undergraduate students may not be interested in initiateing works in this area because the transmission lines studies involve complex models and numeric routines which are truly complex if earth effect and line parameters are considered to be frequently dependent ones.
The objective of this chapter is to introduce concepts about power systems, more especifically, in transmission lines, considering a simplified model of monophasic line in order to analyze electromagnetic transients. [2]-[6].
Considering this purpose, a transmission line can be represented as a monophasic circuit and modeled by circuits (Fig. 1). State variables are used to represent this model. The obtained linear system can be solved by using trapezoidal integration techniques.
OMath>circuit
Based on these conditions, a simplified numeric routine for a first contact of undergraduate students with the study of travelling waves was obtained. This numeric routine can led to a satisfactory precision and accuracy for the simulation of electromagnetic transients for a monophasic line transmission representation. The numeric routine was developed with the use of MatLabTM.
In order to equate the linear system Kirchhoff\'s Laws should be used. Nodal analysis is used to calculate the algebraic sum of the currents. Given that the current in the capacitor is defined as the time derivative of the voltage multiplied by the capacitance factor, the first state equation is obtained. Mesh analysis is used to calculate the algebraic sum of the voltages, the voltage across the inductor is defined as the time derivative of the current multiplied by the inductance factor, the second state equation is obtained.
A linear system can be described algebraically by using state equations variables as it follows:
where: x – vector of state variables;
u – vector of linear system entries;
A and B – matrices which feed the system.
The solution of this system can be obtained numerically by trapezoidal rule.
On the other hand, to solve the linear system of equations of state variables above, an interactive method can be used, where T is the integration step applied for the system solution. For time domain simulations, the integration step is a time step.
Rearranging equation (2), one can obtain:
Solving this equation by using numeric methods, the equation can be rewritten as:
Verifying the equation (4), there are some constant terms, thus the equation can be simplified to:
A’, A’’ e B’ are constant matrices and can be described by the following equations:
In these equations, I is eye matrix of order
The line transmission model for analysis without frequency influence over longitudinal parameters is based on a cascade of
For the transmission line represented in Fig. 2, the A matrix is described in Eq. 7. In this case, the A matrix has a special format; it’s a sparse matrix, with elements non null in the three diagonals as seen below.
Transmission Line Model
In the main diagonal of the A matrix, there are the negative values of the parameters alternating between
The A matrix is a matrix of order
On the other hand, the modeling of frequency influence over longitudinal parameters can be done when introduced branches in parallel of resistor and inductor associated in series with the main branch in series of an inductor and a resistor, in each
media/image6.png#4.5;13.5> circuit considering frequency dependency
The parameters
From analysis of Kirchhoff’s Laws of the current in the inductor and the voltage in the capacitor, the linear system of state variables is obtained.
where, each
For
The lower matrices contain just one non null element which is in the last column in first line and it’s described by
Each element of x has the following structure:
This state equation describes the transmission line represented by n
The routine used for introducing the proposed model shown in previous items is implemented in MatLabTM software. For this, only basic notions of programming are necessary to make the development of this routine easy for undergraduate students. Initially, the source values, the number of
Where R’, L’, C’, G’ are the line parameters per unit length, d is the length of the line and n is the number of
In the case of frequency influence the user may choose the number of branches and also specify the value for each resistor and inductor. These values can be calculated by using any routine that considers the frequency influence in transmission line parameters. After this step, the simulation time (t), the time step (T) and the sources that are connected at the line are defined. Then, the equation that describes each source should be introduced in the numeric routine by using a specific MatLab™ tool. Simulations of electromagnetic transient of many different input signals can be obtained just by inserting their functions in MatLabTM program routine as seen in Fig. 4. After specifying all the input values, the routine generates the A and B matrices and also the input vector U in discrete time. Then, the equation (6) terms are calculated numerically by using the chosen time step and the simulation time. The chosen current and voltage output results are uploaded in a vector file. Finally, a graph is plotted with the results of the simulation.
MatLab window.
In order of results, both routines, with and without frequency influence, will be shown and discussed step by step. The objective of these routines is to show how to use MatLabTM by using simple functions or commands to present the wave propagation of current or voltage to undergraduate students. The functions and commands used into routine will be explained; also the loops and conditions used into it will also be explained below the routine.
The first routine doesn’t consider the frequency influence.
MatLab.. code %Clear variables and command window clear; clc; %Close windows Close all; %Definitions of Entrance Elements disp(\'Transmission Line Analyze\') P = input (\'Enter the Number of Pi Circuits = \'); D = input (\'Enter the line length (km) = \'); R = input (\'Enter the value of distributed resistance (ohm/km) = \'); L = input (\'Enter the value of distributed inductance (H/km) = \'); C = input (\'Enter the value of distributed capacitance (F/km) = \'); G = input (\'Enter the value of distributed conductance (S/km) = \'); T = input (\'Set time step [s]: \'); t = input (\'Enter the simulation total time [s]: \'); %Distributed Elements R=R*D/P; L=L*D/P; G=G*D/P; C=C*D/P; %e = Pi circuits which will receive entries cont=1; while (i ~= 0) clc; disp(\'Indicate the input kind:\'); disp(\'1 - Voltage\'); disp(\'2 - Current\'); disp(\'0 - Exit\'); i = input(\'\'); if (i==1) e(cont)= input (\'\\n Indicate the pi circuit = \'); fun = input(\'\\n Enter the function:\'); fun = inline(fun); u(2*e(cont)-1,1) = fun; end if (i==2) e(cont)= input (\'\\n Indicate the pi circuit= \'); fun = input(\'\\n Enter the function:\'); fun = inline(fun); u(2*e(cont),1) = fun; end cont=cont+1; end %A matrix for j=1:(2*P-1) h = rem(j,2); if h==1 A(j,j)= -(R/L); A(j,j+1)= -(1/L); A(j+1,j)= 1/C; else A(j,j)= -(G/C); A(j,j+1)= -(1/C); A(j+1,j)= 1/L; end end %A (2*P,2*P) A(2*P,2*P)=-(G/C); %B matrix B(2*P,1)=0; for j=1:numel(u) h = rem(j,2); if h==1 B(j,j)=1/L; else B(j,j)=1/C; end end %Constant terms A1=inv(eye(2*P)-(T/2)*A); A2=(eye(2*P)+(T/2)*A); A2=A1*A2; B1=(T/2)*B; B2=A1*B1; x(2*P,1)=0; %Iterations to solve the linear system j=1; for q= 0: T: t u1=feval(u,q); u2=feval(u,q+T); x=A2*x+B2*(u1+u2); y(j,1)=q; y(j,2)=x(2*P,1); y(j,3)=x(2*P-1,1); j=j+1; end plot(y(:,1),y(:,2),\'b\') title(\'Voltage in the end of transmission line\'); ylabel(\'Voltage [kV]\'); xlabel(\'Time [s]\'); pause plot(y(:,1),y(:,3),\'r\') title(\'Current in the end of transmission line\'); ylabel(\'Current [A]\'); xlabel(\'Time [s]\'); |
In the beginning of the routine some commands are used like:
- clear all: cleans all the variables existents in MatLabTM.- clc: cleans the command window.- close all: closes all the graphics opened.
The command disp shows a message in the command window for users to know what happens in the routine, that way no one thinks the routine is not working, because sometimes, it does take a lot of time to finish all the procedures, thus, a message is important to enlighten that.
The command input asks the user to insert a value for a variable, instead of defining a constant value inside the routine, this command makes it more interactive, so the user can put any value wanted and analyze the answer for different values inserted.
The loop while is used with the purpose to insert voltage or current sources as many as the user wants. The user will specify if the source is of voltage (1) or current (2), after specifying the kind of source, it shall specify the
Indicate the input kind:
1 – Voltage
2 - Current
0 - Exit
Indicate the pi circuit = 1
Enter the function: ‘1’
For mounting the A matrix a loop for is used because the number of interactions is known, inside the loop the command if is used to construct the mainly, upper and lower diagonals as shown in Eq. 7. The same is done in the B matrix.
Finally, a loop for is used to solve the trapezoidal rule considering the time step and the total time elapsed. The variable y retains in the first column the value of steps of time, the second column retains the value of voltage, and the third column retains the value of current in the terminal of the line transmission.
Fig. 4 shows the previous version of the routine, in that routine the command syms was used. This command creates a symbol as a variable to solve this. The command subs must be used, in order to substitute the variable in the function with the value requested. In this case, the function entry of current or voltage source didn’t need to be inserted as a string, but the user always had to insert the function by using the variable specified, what was not always done. The second purpose used the command inline which gets a string and converts it into a function; with this command the user can use any variable, to solve this in the trapezoidal rule. It’s used the command feval, which gets the function and substitutes the values with the time step.
The second routine considers the frequency influence. Almost all the steps used in this routine were the same as shown in the first one. Only the different steps done here will be described.
MatLab code %Clear variables and command window clear all; clc; %Close all graphic windows close all; disp(\'Transmission Line Analysis\'); sprintf(\'\\n\'); P = input (\'Enter the Number of Pi Circuits = \'); D = input (\'Enter the line length (km) = \'); %It\'s defined R(1) and L(1) which represents R0 and L0 respectively, %values of R1, L1, ... Rm, Lm, will be with a plus number. R(1) = input (\'Enter the value of distributed resistance (ohm/km) = \'); L(1) = input (\'Enter the value of distributed inductance (H/km) = \'); C = input (\'Enter the value of distributed capacitance (F/km) = \'); G = input (\'Enter the value of distributed conductance (S/km) = \'); m = input (\'Enter the number of coupling circuits = \'); for i=2:m+1 R(i) = input ([\'Enter the value of resistance of the branch \' int2str(i-1) \' [ohm/km] = \']); %Distributed Resistance R(i) = R(i)*D/P; L(i) = input ([\'Enter the value of inductance of the branch \' int2str(i-1) \' [H/km] = \']); %Distributed Inductance L(i) = L(i)*D/P; end %Time step and total time T = input (\'Set time step [s]: \'); t = input (\'Enter the simulation total time [s]: \'); %Distributed Elements R(1)=R(1)*D/P; L(1)=L(1)*D/P; G=G*D/P; C=C*D/P; %A matrix A=zeros(size(P*(m+2))); c=0; for i=1:m+1 A(i,i)=-R(i)/L(i); A(1,i)=R(i)/L(1); A(i,1)=-A(i,i); end %First term as positive A(1,1) = -A(1,1); for i=1:m+1 %c variable will get the values to put in A(1,1), uses recall c=A(1,i)+c; end A(1,1)=-c; %Terminal elements of matrix A(1,m+2)=-1/L(1); A(m+2,1)=1/C; A(m+2,m+2)=-G/C; %Mainly matrix AP=A; %Putting the matrix in all the positions for j=1:(P-1) AP(j*(m+2)+1:(j+1)*(m+2),j*(m+2)+1:(j+1)*(m+2))=A; end %Lower matrix AI(1,m+2)=1/L(1); AI(m+2,m+2)=0; %Upper matrix AS(m+2,1)=-1/C; AS(m+2,m+2)=0; %Putting the lower and upper matrices in their places for j=1:(P-1) AP(j*(m+2),j*(m+2)+1)=-1/C; AP(j*(m+2)+1,j*(m+2))=1/L(1); end %Element of the first matrix A(m+2,1)=2/C; %Element of last matrix A(P*(m+2),1)=2/C; %e = Pi circuits which will receive entries %cont sets which pi circuit will receive the entry cont=1; while (i ~= 0) clc; disp(\'Indicate the input kind:\'); disp(\'1 - Voltage\'); disp(\'2 - Current\'); disp(\'0 - Exit\'); i = input(\'\'); if (i==1) e(cont)= input (\'\\n Indicate the pi circuit = \'); fun = input(\'\\n Enter the function:\'); fun = inline(fun); u(e(cont)*(m+2)-(m+1),1) = fun; end if (i==2) e(cont)= input (\'\\n Indicate the pi circuit = \'); fun = input(\'\\n Enter the function:\'); fun = inline(fun); u(e(cont)*(m+2),1) = fun; end cont=cont+1; end %Clear the command window clc; disp(\'PROCESSING...\'); %B matrix B(P*(m+2),1)=0; for j=1:m+2:numel(u) h = rem(j,2); if h==1 B(j,j)=1/L(1); else B(j,j)=1/C; end end A1=inv(eye(P*(m+2))-(T/2)*AP); A2=(eye(P*(m+2))+(T/2)*AP); A2=A1*A2; B1=(T/2)*B; B2=A1*B1; %x matrix x(P*(m+2),1)=0; j=1; for q = 0: T: t u1=feval(u,q); u2=feval(u,q+T); x=A2*x+B2*(u1+u2); y(j,1)=q; y(j,2)=x(P*(m+2),1); y(j,4)=x(P*(m+2)/2,1); %middle of line y(j,3)=x(P*(m+2)-(m+1),1); y(j,5)=x((P*(m+2)/2)-(m+1),1); %middle of line if (q==30*T) for kk = 1:P z(kk,1)=kk*D/P; z(kk,2)=x(kk*(m+2),1); end end if (q==60*T) for kk = 1:P z(kk,3)=x(kk*(m+2),1); end end if (q==90*T) for kk = 1:P z(kk,4)=x(kk*(m+2),1); end end if (q==120*T) for kk = 1:P z(kk,5)=x(kk*(m+2),1); end end if (q==150*T) for kk = 1:P z(kk,6)=x(kk*(m+2),1); end end if (q==180*T) for kk = 1:P z(kk,7)=x(kk*(m+2),1); end end if (q==210*T) for kk = 1:P z(kk,8)=x(kk*(m+2),1); end end if (q==240*T) for kk = 1:P z(kk,9)=x(kk*(m+2),1); end end if (q==260*T) for kk = 1:P z(kk,10)=x(kk*(m+2),1); end end if (q==290*T) for kk = 1:P z(kk,11)=x(kk*(m+2),1); end end if (q==310*T) for kk = 1:P z(kk,12)=x(kk*(m+2),1); end end if (q==330*T) for kk = 1:P z(kk,13)=x(kk*(m+2),1); end end if (q==360*T) for kk = 1:P z(kk,14)=x(kk*(m+2),1); end end if (q==390*T) for kk = 1:P z(kk,15)=x(kk*(m+2),1); end end j=j+1; end plot(y(:,1),y(:,2),\'b\') title(\'Voltage in the end of transmission line\'); ylabel(\'Voltage [kV]\'); xlabel(\'Time [s]\'); pause plot(y(:,1),y(:,3),\'r\') title(\'Current in the end of transmission line\'); ylabel(\'Current [A]\'); xlabel(\'Time [s]\'); pause plot(z(:,1),z(:,2),\'b\',z(:,1),z(:,5),\'r\',z(:,1),z(:,11),\'g\',z(:,1),z(:,15),\'k\') title(\'Voltage in line path\'); ylabel(\'Voltage [kV]\'); xlabel(\'Length (km)\'); |
This routine uses the loop for in the beginning to obtain all the values series branches. The user specifies the amount of series branches and enters the resistance and inductance values for each branch. In the last loop for, a sequence of if is used to obtain the wave propagation in different time instants. This is a very important part of the routine, because it shows how the voltage or current waves propagates into the line. This representation shows to undergraduate students that a signal put in the beginning of line will not appear instantaneously in the end of line. It takes a little time, like milliseconds to arrive at the end, because the length of the line is considered, differently from a bipole, the signal put in a terminal is at the other terminal at the same time. Another observation is that, with the EMTP type programs, the user can only analyze a specific point of the circuit and in this case in a time range. The routine shows how the wave propagates into the line for different line points in the time instant.
For all simulations the following values were used: the number of π circuits was 100 and the transmission line has 10 kilometers. The resistance value was
Resistors (Ω) | Inductors (mH) | ||
R0 | 0,026 | L0 | 2,209 |
R1 | 1,470 | L1 | 0,74 |
R2 | 2,354 | L2 | 0,12 |
R3 | 20,149 | L3 | 0,10 |
R4 | 111,111 | L4 | 0,05 |
Longitudinal parameters values using the routine considering the frequency influence
A simulation was made for voltage input unitary step signal. It was a step function with a unitary step after
Voltage in the end of transmission line by using routine without frequency influence.
Voltage in the end of transmission line by using routine with frequency influence
Current in the end of transmission line by using routine without frequency influence.
In Figs. 7 and 8, it’s possible to observe the influence of frequency in the current. Without frequency influence the signal is very disturbed. On the other hand, when it is used the routine that considers frequency influence, it is noticed that in the end of the line it should not have any current, supposing an end line opened, but, there are some transients because of the last branch. As in voltage signal, the current signal is damped because of the series branches in circuit. By using the routine of frequency influence, it can also be obtained how the voltage signal goes to the path of line for the time in Fig. 9.
Current in the end of transmission line by using routine with frequency influence.
Voltage in line path.
By using a mono-phase circuit representation of transmission lines associated to the state variables and the trapezoidal rule,
The shown numeric routine is simple and because of this, it can be used by undergraduate students for their first contact with electromagnetic transient phenomena, by traveling wave propagation, transmission line analyses. For the first contact with wave propagation simulations for undergraduate students, the proposed routine is an excellent tool. It is simple and its use is easy. So, by using basic concepts of traveling wave, linear systems and computing, it is possible to manipulate the numeric routine, observing the wave propagation characteristics, such as time delays, wave reflection and refraction, numeric oscillations (Gibbs’ oscillations), transient oscillations. For undergraduate students, it is possible to compare the results and the modeling of the electromagnetic transients in transmission lines considering or not frequency dependent line parameters. This is possible by accessing the proposed routine numeric code. In courses related to the transmission line area, the manipulation of this code can make the course more interesting for the undergraduate students. These advantages are added to the other ones that are shown in this chapter and related to the application of the MatLabTM software. The use of this software makes the implementation of the mentioned routine extremely easy.
According to the literature of the last 20 yrs., the majority of patients with acute appendicitis should be treated conservatively and not by surgery, as they do not benefit from appendectomy and the operation is considered unnecessary. Unfortunately, worldwide surgical treatment of acute appendicitis remain the gold standard treatment of choice; in a recent multi-centric study in 2018 [1], based in a large number of patients with acute appendicitis, more than 95% of patients were treated by surgery, while conservative treatment underwent less than 5% of the patients. Taking into account the recent literature, the percentages for correct treatment, should be: 80–95% conservative treatment and 5–15% surgical treatment. At the present study we review and analyze the role of many parameters, influencing the clinical presentation of the patient, the correct diagnosis and decision making for the proper treatment. The role of etiology, pathology and anatomy of acute appendicitis is analyzed. In addition the role of predictive markers/factors, inflammatory markers and radiological data, linked with diagnosis-evolution and severity of acute appendicitis is discussed. Emphasis is given in clinical presentation of the patient and the decision making for conservative or surgical treatment.
\nAt the moment the appendicular inflammation, is quiet obscure and multifactorial. Carr et al. in a review article [2], describes and analyses several etiologies of acute appendicitis; infection, trauma, ischemia, diet factors, genetic factors, foreign bodies, hygiene and type I hypersensitivity may lead to acute appendicitis. The corresponding pathology reports containing a large spectrum of minor or major changes in mucosa, sub-mucosa, appendicular wall and peri-appendicular area, defining the acute appendicitis as catarrhal, suppurate (phlegmonous), gangrenous (necrotizing) or with signs of peri-appendicitis. Theoretical conceptions about the role of fecolith or lymphoid hyperplasia, creating luminal obstruction, today are under-estimating, as there are severe controversies in medical reports; in pathology reports rarely is found lymphoid hyperplasia with luminal obstruction, on the other hand the percentage of fecoliths in acute appendicitis (7–15%), is lower than in autopsies or in general population, studied with modern imaging studies, performed for other medical reasons (up to 30%). So their implication to inflammatory process is unclear with minor importance. Hence the question: what’s the real etiologic factor of acute appendicitis? And what’s really happens in appendicular wall? This poses some confusion about the conception of surgeon regarding the treatment of acute appendicitis; conservative or by surgery? In this heading, despite the obscure etiology, there are two key points; a) we must exclude secondary appendicitis, due to tumors of the cecum, appendix or peri-appendicular area. As acute appendicitis is a disease of the middle age (3rd and 4th decade of the life), we must be careful, mostly in aged patients (>50 years, or > 65 yrs. old) with acute appendicitis, although this group of patients represent a small percentage (7–15%) of the patients presented [3]. If conservative treatment is decided, after the acute phase, a colonoscopy and CT scan of the lower abdomen must be performed. b) Inflammatory process of the appendix starts initially at the level of mucosa and sub-mucosa, invaded by neutrophils and sometimes by eosinophils. Later, ulcers may appear [2] and the appendicular wall may be invaded by anaerobes, gram negatives and other microbial agents. This evolution explains the use of antibiotics for the regression of inflammation, if conservative treatment is decided. A multi-centric study (APPAC trial), provide level I evidence data, that antibiotic treatment for uncomplicated acute appendicitis is effective and reduce the rate of appendectomies by 75–85% [4]. Following the natural history of acute appendicitis, a self-regression of the inflammation is feasible at 20% of patients [5]. Having in mind that at the beginning of appendicitis the inflammation involves mucosa and sub-mucosa, one should think the use of anti-inflammatory drugs. At the moment, worldwide, there are not reports for the use of such drugs as a part of conservative treatment. The author, in selected patients with acute uncomplicated appendicitis, used a combination of paracetamol and lornoxicam (an analgesic scheme, often used to treat postoperative pain), as the main treatment in a study with more than 100 patients with uncomplicated acute appendicitis [6], with early onset and duration of symptoms. It seems that this kind of treatment combined with antibiotics, offers promptly a clinical and laboratory regression of acute appendicitis. Non-steroidal anti-inflammatory drugs may play an important role in conservative treatment, as such effectiveness is observed in other inflammatory intra-abdominal inflammations; e.g. in acute cholechystitis, (chemical inflammation, without microbial involvement at least at the start of inflammatory process). This is a new field of research, although some parameters must be determined: the kind and time (days) of anti-inflammatory therapy, the effectiveness in cases with early onset of symptoms in acute appendicitis, and their use in purulent appendicitis in combination with antibiotics.
\nRLQ pain and rebound tenderness- aka the classic symptoms of acute appendicitis- accounts at about 40% of patients. In a review study [7], a high percentage of variable position and other anatomic characteristics of the appendix, as the length or orientation, may confuse clinicians. Such cases should be studied by modern imaging studies. One should keep in mind that the position of the appendix is extremely variable; De Souza et al., in a retrospective study of 377 cases [8], describes the most common position of appendix during surgery, as follows: retro-cecal location at 43.5%, sub-cecal at 24.5%, post-ileal at 14.3%, pelvic at 9.3%, para-cecal at 5.8%, pre-ileal at 2.4% and other at 0.27%.
\nNo. Abdominal pain in the right iliac fossa, do not always correspond to acute appendicitis. Negative appendectomies in bibliography vary from 10 to 45% and especially in females. The percentage of misdiagnosed cases is 10%. Using imaging studies; the percentage of negative appendectomies is still at 10–12% [9]. Correct diagnosis is the most difficult step in evaluation of acute appendicitis; what really happens in the intra-abdominal cavity? By meticulous estimation of clinical and laboratory data and necessary imaging data, this parameter may be evaluated quiet good at the present time. Various scoring systems increase the diagnostic accuracy. The older is a clinical one described by Alvarado since 1986. This score may predict acute appendicitis [10], being a useful diagnostic aid, especially for younger colleagues [11]. The AIR score, incorporates CRP as a variable in the score and is more accurate at predicting appendicitis than Alvarado score in those deemed high risk [12]. At the present time, newer scoring systems are used, combining clinical and imaging features, and they also have an important role to distinguish uncomplicated from complicated cases of acute appendicitis [13]. Score systems can aid in selection of patients for surgical or non-surgical management. Various markers are used in scoring systems using parameters from physical, laboratory and imaging studies; age, body temperature, the duration and time of onset of symptoms, white blood cell count (WBC), CRP level, presence of peri-appendicular fluid, extra-luminal free air and the presence or not of a appendicolith in U/S or CT.
\nThe majority of studies reveal a percentage of complicated appendicitis at 5% and uncomplicated cases at 95% [13]. Other reports present a higher percentage of complicated cases up to 20–25%. Trying to select patients for conservative treatment, may be difficult preoperatively. The best categorization may be done after surgery, combining surgical findings during surgery; appendix status, the effect of inflammation in peri-appendicular areas and peritoneum, and the final pathology report. Even thought, there is heterogeneity in terms used, to describe the type of acute appendicitis. The most often used terms are; simple appendicitis, uncomplicated acute appendicitis, catarrhal appendicitis, purulent appendicitis, complicated acute appendicitis with abscess or phlegmon, dehiscence or rupture of appendicular wall, gangrenous appendicitis, local or diffuse peritonitis, and fecal peritonitis. Laparoscopy offers a correct grading of acute appendicitis [14]. Emphasis is given in complicated cases (grade 3–5) but they represent a small percentage in the total number of patients, with acute appendicitis. Its position for uncomplicated cases (grade 1, 2) is not well determined. Pathology changes and clinical data in ICD-10 system classification, determine 8 types or subtypes of acute appendicitis;
\nICD-10: K35 - acute appendicitis.
\nICD-10: K35.2 - acute appendicitis with generalized peritonitis.
\nICD-10: K35.3 - acute appendicitis with localized peritonitis.
\nICD-10: K35.8 - other and unspecified acute appendicitis.
\nICD-10: K35.80 - unspecified acute appendicitis.
\nICD-10: K35.89 - other acute appendicitis.
\nICD-10: K36 Other appendicitis.
\nICD-10: K37 Unspecified appendicitis.
\nThe history of the disease, clinical examination, WBC, CRP, U/S or CT findings contribute to diagnosis [15] and predict the severity and evolution of acute appendicitis. Postoperative complications are related to the pathology, the contribution of bacteria in inflammation and the type of operation. Early diagnosis in the first 48 h, may be important followed be early management of the disease, and probable for more conservative approach, as antibiotic treatment is a safe and first line therapy for acute appendicitis, with excellent results in uncomplicated cases (patients without diffuse peritonitis), reducing the unnecessary appendectomies [16]. The non-surgical management of uncomplicated appendicitis by the use of antibiotics, predominates as treatment option as it’s effective and decreases morbidity [17]. Patient delay for clinical examination and diagnosis is the key factor linked with an increased incidence of complicated acute appendicitis [18]. Today, the use of radiological interventional techniques in combination with antibiotics, extent the spectrum of conservative treatment in many complicated cases of acute appendicitis, as there is possibility for successful treatment-drain of the intra-abdominal abscesses and phlegmon [19], reducing complications compared with surgical treatment [20]. Surgery in such complicated cases is not easy and may lead in right hemi-colectomy due to severe intra-abdominal inflammation during surgery. We consider this effect a catastrophic result of surgery for a benign inflammatory process, in the absence of a local tumor in appendicular and peri-appendicular area.
\n\n
The age and sex of the patient; all reports, mention a disease of the middle age and the majority of patients are between 29 and 40 years old, although the age rage varies from the infantile to older ages. In younger ages exclusion or the presence of septic variables is important, as option treatment must be decided as soon as possible. In older ages, >50 years or 65 yrs. old, the possibility for complicated cases and the presence of an appendicular or peri-appendicular tumor is higher than in the middle age. Elderly patients present a higher mortality, morbidity, higher perforation rate, higher postoperative complication rate, lower diagnostic accuracy and longer delay from symptoms onset and admission [21], the female sex presents a more difficult diagnosis, mainly in reproductive age. Gynecological conditions and acute appendicitis may be studied in emergency by U/S combined with trans-vaginal ultrasound [22], increasing the diagnostic accuracy for acute appendicitis.
The past history (start and duration of symptoms) may be false; the patient many times refers a short period of time with symptoms. Acute appendicitis may have atypical clinical presentation (up 30% of the patients), the existence of atypical location of the appendix, and the presence of the disease in advanced ages creates a vague past history, leading in a wrong option treatment.
Analyze the features of the pain; complete clinical examination of the abdomen, with emphasis in palpation of the abdomen. We can diagnose the local signs of inflammation or sings of generalized peritonitis. Deep pain, in deep palpation of the right iliac fossa (visceral pain) reveals the local inflammation. Irritation of the peritoneum is expired by rebound (somatic pain). Colic pain may reveal an appendicular fecolith or intestinal obstruction due to severe inflammation-periappendicular inflammatory mass or tumor. Colic pain coexists more times with a permanent local-visceral pain. Sometimes acute appendicitis is manifested with reflex pain in the right hypochondrium, peri-umbilical, epigastria area or left iliac fossa, with no or attenuated local signs in the right lower quadrat. Reflex pain disappear in a short period of time of some hours and finally appear and predominate local signs of visceral pain in the right lower quadrat. We consider that clinical examination of the abdomen is the optimal method for diagnosis and estimation of severity in patients with acute appendicitis, as it’s a fast, easy and may be repeated at times. Surgeon’s opinion for acute appendicitis, in combination with laboratory and imaging data yield the best outcomes in patients, for the correct diagnosis in acute appendicitis [23].
There are many inflammatory markers that can be used. Increased levels reflect the severity of acute appendicitis. Very high levels may reveal more complicated cases or sepsis [24]. WBC and neutrophil ratio, CRP, procalcitonine and SER are the most often used markers. We recommend the use of WBC and CRP. They are available in most laboratories and the results are taken in a short time. The use of numerous or novel markers is not recommended as they do not improve the diagnostic ability for acute appendicitis [25].
\nThere are three radiologic examinations available; U/S, CT and MRI [26]. U/S dispose a high diagnostic accuracy for acute appendicitis >90% but a high negative predictive value [27] with limited sensitivity, as the no visualization of appendix during U/S is very often observed. If inconclusive data are reported, and clinic-laboratory data support the presence of acute appendicitis, further study with CT (when there is no pregnancy) or MRI is recommended [28]. There are five morphological imaging criteria of appendicitis; a. enlargement (diameter) of the appendix>6 mm, b. thickness of the appendicular wall>2 mm, c. Inflammatory compression of the peri-appendicular adipose tissue, d) abscess formation in the right lower abdomen, e) calcified appendicolith. The three first criteria reveal uncomplicated acute appendicitis. A contrast-enhanced CT is an excellent tool for complicated cases and visualization of appendicular wall dehiscence-rupture.
\n\n
Pregnancy: Acute appendicitis in pregnancy is a complex situation, and collaboration between obstetrics and surgeons offer the best outcomes for mother and fetus [29]. Severe perforated cases of appendicitis and negative appendectomies may lead to premature delivery [30]. There is need for accurate diagnosis and correct option treatment. Most cases are observed in the second trimester of the pregnancy. CT is contraindicated do to pregnancy. Diagnostic imaging data are obtained by U/S and MRI. MRI yields a high diagnostic rate and accuracy in pregnant and guide further option treatment [31].
Gangrene of the appendix (or necrotizing appendicitis); it’s a special type of appendicitis. There is need for accurate diagnosis and surgery due to generalized peritonitis and sepsis. Recently appear reports for conservative treatment of level evidence II [32]. It’s more often observed in pediatric population and represents a percentage of 12–13% in pathology reports. In adults is a rarer phenomenon with lower percentage. The incidence is not well determined as in pathology reports different terms are used; gangrenous appendicitis, complicated appendicitis, perforated appendicitis, or necrotizing appendicitis and the percentage of this group with complicated cases is 10–25% in different reports [33].
Immunosuppressed patients; Surgery is the rule to avoid sepsis and deaths.
After the clinical examination, collection of inflammatory markers and imaging data. This waiting time for few hours, assure a correct diagnosis, the option treatment and do not influence the pathology report if appendectomy will be decided. As more variables are positive for acute appendicitis, the diagnostic accuracy for acute appendicitis is high. Cases should be categorized for the severity. Uncomplicated cases and selected complicated cases of acute appendicitis should be treated conservatively with benefits for patients. Diffuse peritonitis and the evidence of perforated appendix represent surgical cases.
\nAdmission in the hospital, and active observation according to the needs of the patient. Collection and estimation of inflammatory markers and imaging data. Soft feeding is permitted if there is not nausea, intestinal obstruction or planning for operation. Correction of fluid imbalances due to inflammation. The use of antibiotics is mandatory as is the main therapy in conservative treatment. Antibiotic treatment is performed, according to the instructions for the treatment of intra-abdominal infections [34] and a short scheme of 4 days may be effective, at least in uncomplicated cases. After conservative treatment, an interval time for further intervention tend to be abandoned [35] even more for complicated cases with abscess or phlegmon.
\nThe re-appearance of acute appendicitis after conservative treatment is not easy to be calculated. Most reports mention a percentage of 7–10% with a long period of follow-up [36]. There is a lack of information and heterogeneity about the kind-results of conservative treatment (during the first episode of acute appendicitis). Usually, surgery is followed after a new episode. The pathology report should describe changes of acute appendicitis and not chronic inflammatory changes in mucosa or sub-mucosa, as is the case after appendectomy due to recurrent episodes.
\nConservative treatment of patients with acute appendicitis is not very popular in surgical community, despite ongoing literature data supporting its role in the majority of patients with uncomplicated and selected cases of complicated acute appendicitis. Uncomplicated cases accounts for the 80–90% of patients with acute appendicitis. At every day’s practice, more than 90% of uncomplicated cases undergoing appendectomy and less than 10% are treated conservatively. Conservative treatment should be offered, as an initial approach, to every patient with acute appendicitis. Surgeons should understand that the majority of patients may not need and they do not benefit from appendectomy.
\nThe authors declare no conflict of interest.
RLQ | right lower quadrat |
AIR | appendicitis inflammatory response |
CRP | C-reactive protein |
WBC | white blood cell count |
U/S | ultrasounds |
CT | computerized tomography |
MRI | magnetic resonance imaging |
SER | sedimentation erythrocyte rate |
ED | emergency department |
.
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\n\nThe combined printing and delivery times for orders vary from 12-20 business days, depending on the printed quantity and destination. This period does not include any customs clearance difficulties that may arise and that are beyond our control. Once your order has been printed and shipped, you will receive a confirmation email that includes your DHL tracking number. You can then track your order at www.dhl.com.
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\n\nPOD products are non-returnable and non-refundable, except in the event of poor print quality or an error in quantity. If we delivered the item to you in error or the item is faulty, please contact us. Inspect your order carefully when it arrives. Any problems should be immediately reported to orders@intechopen.com.
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