Introduction: Delayed or wrong diagnosis in patients with appendicitis can result in perforation and consequently increased morbidity and mortality. Serum total bilirubin may be a useful marker for appendiceal perforation. The aim of this study was to determine and compare pre-operative total bilirubin level and other diagnostic tools (patient age, duration of symptoms, Alvarado score, white blood cell, C-reactive protein, ultrasound and contrast enchanced CT scan) in cases of acute appendicitis in order to improve the clinical decision making. Materialsand methods: We identified 102 patient with acute appendicitis after excluding those with other causes of hyperbilirubinemia among the 180 patients that underwent a laparoscopic or an open appendectomy from June, 2011 to March, 2015 in UB Songdo Private Hospital. These cases were also subjected to liver function tests and clinical diagnosis was confirmed perioperatively and postoperatively by histopathological examination. According to histological results, these cases were classified two groups: positive(acute appendicitis with perforation and/or gangrene) and negative(acute appendicitis without perforation or gangrene). Their clinical and investigative data were compiled and analyzed. Statistical analysis was performed using independent sample t test, Chi square test, and direct logistic regression. The level of significance was set at P< 0.05. Results: Serum total bilirubin was found to be significantly increased(1,5mg/dL) in case of negative group and much higher (3,6mg/dL) in cases of positive group (P <0.001). The level of total bilirubin was higher than 3 mg/dL in cases of gangrenous/ perforated appendicitis while in cases with acute appendicitis it was lower than 3 mg/ dL. Also Alvarado score (P <0.01), C-reactive protein (P <0.001) and contrast enchanced CT scan (P <0.05) were statistically significant diagnostic tools for acute appendicitis. Conclusion: Assessment of preoperative total bilirubin is useful for the differential diagnosis of gangrenous/perforated appendicitis.

Introduction: Delayed or wrong diagnosisin patients with appendicitis can result inperforation and consequently increasedmorbidity and mortality. Serum total bilirubinmay be a useful marker for appendicealperforation. The aim of this study wasto determine and compare pre-operativetotal bilirubin level and other diagnostictools (patient age, duration of symptoms,Alvarado score, white blood cell, C-reactiveprotein, ultrasound and contrast enchancedCT scan) in cases of acute appendicitis inorder to improve the clinical decision making.Materialsand methods: We identified102 patient with acute appendicitis afterexcluding those with other causes ofhyperbilirubinemia among the 180 patientsthat underwent a laparoscopic or an openappendectomy from June, 2011 to March,2015 in UB Songdo Private Hospital.These cases were also subjected toliver function tests and clinical diagnosiswas confirmed perioperatively and postoperativelyby histopathological examination.According to histological results, these caseswere classified two groups: positive(acuteappendicitis with perforation and/organgrene) and negative(acute appendicitiswithout perforation or gangrene). Theirclinical and investigative data were compiledand analyzed. Statistical analysis wasperformed using independent sample t test,Chi square test, and direct logistic regression.The level of significance was set at P< 0.05.Results: Serum total bilirubin was foundto be significantly increased(1,5mg/dL) incase of negative group and much higher(3,6mg/dL) in cases of positive group (P<0.001). The level of total bilirubin washigher than 3 mg/dL in cases of gangrenous/perforated appendicitis while in cases withacute appendicitis it was lower than 3 mg/dL. Also Alvarado score (P <0.01), C-reactiveprotein (P <0.001) and contrast enchanced CTscan (P <0.05) were statistically significantdiagnostic tools for acute appendicitis.Conclusion: Assessment of preoperativetotal bilirubin is useful for the differentialdiagnosis of gangrenous/perforatedappendicitis.

Flail arm syndrome (FAS), an atypical variant of amyotrophic lateral sclerosis (ALS), is characterized by progresses slowly, predominantly proximal, weakness of upper limbs, with no involvement of the lower limb, bulbar, or respiratory muscles. In the world, 1-3 cases per 100,000 people per year are registered. Incidence is higher among whites. The peak age is 55-75 years, although it can occur at a younger age. The male gender is dominant. Signs of upper motor neuron (UMN) lesions of the cervical region in flail arm syndrome patients are rare. The lack of information regarding FAS may make differential diagnosis between flail arm syndrome, upper limb onset amyotrophic lateral sclerosis and other lower motor neuron syndromes difficult in clinical settings. The prognosis of FAS is better than that of upper limb ALS and most cases of FAS are sporadic. Therefore, a reliable differential diagnosis is essential to determine the prognosis. Compared with the other varient of ALS, clinical symptoms progress over a relatively long period of time in flail hand syndrome, with a median survival of 4 years and a 10-year survival of 17%. We report a 79 year old patient admitted to the hospital with a 1 year history of proximal weakness and 2 arm shoulder girdle muscle stiffness, wasting and 2 arm m.deltoideus fasciculations with Flail arm syndrome. It was one of the few cases of arm drooping syndrome, which begins only with weakness, stiffness, and symmetry in the proximal part of the upper limbs. Definite ALS was diagnosed based on clinical examination /neurological abnormalities/ and electromyography results.