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Stiel C, Elrod J, Klinke M, Herrmann J, Junge CM, Ghadban T, Reinshagen K, Boettcher M. The Modified Heidelberg and the AI Appendicitis Score Are Superior to Current Scores in Predicting Appendicitis in Children: A Two-Center Cohort Study. Front Pediatr 2020; 8:592892. [PMID: 33313029 PMCID: PMC7707101 DOI: 10.3389/fped.2020.592892] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2020] [Accepted: 10/16/2020] [Indexed: 12/29/2022] Open
Abstract
Background: Acute appendicitis represents the most frequent reason for abdominal surgery in children. Since diagnosis can be challenging various scoring systems have been published. The aim of this study was to evaluate and validate (and improve) different appendicitis scores in a very large cohort of children with abdominal pain. Methods: Retrospective analysis of all children that have been hospitalized due to suspected appendicitis at the Pediatric Surgery Department of the Altonaer Children's Hospital and University Medical Center Hamburg-Eppendorf from 01/2018 until 11/2019. Four different appendicitis scores (Heidelberg Appendicitis Score, Alvarado Score, Pediatric Appendicitis Score and Tzanakis Score) were applied to all data sets. Furthermore, the best score was improved and artificial intelligence (AI) was applied and compare the current scores. Results: In 23 months, 463 patients were included in the study. Of those 348 (75.2%) were operated for suspected appendicitis and in 336 (96.6%) patients the diagnosis was confirmed histopathologically. The best predictors of appendicitis (simple and perforated) were rebound tenderness, cough/hopping tenderness, ultrasound, and laboratory results. After modifying the HAS, it provided excellent results for simple (PPV 95.0%, NPV 70.0%) and very good for perforated appendicitis (PPV 34.4%, NPV 93.8%), outperforming all other appendicitis score. Discussion: The modified HAS and the AI score show excellent predictive capabilities and may be used to identify most cases of appendicitis and more important to rule out perforated appendicitis. The new scores outperform all other scores and are simple to apply. The modified HAS comprises five features that can all be assessed in the emergency department as opposed to current scores that are relatively complex to utilize in a clinical setting as they include of up to eight features with various weighting factors. In conclusion, the modified HAS and the AI score may be used to identify children with appendicitis, yet prospective studies to validate our findings in a large mutli-center cohorts are needed.
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Affiliation(s)
- Carolin Stiel
- Department of Pediatric Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Julia Elrod
- Department of Pediatric Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Michaela Klinke
- Department of Pediatric Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jochen Herrmann
- Section of Pediatric Radiology, Department of Diagnostic and Interventional Radiology and Nuclear Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Carl-Martin Junge
- Department of Pediatric Radiology, Altonaer Kinderkrankenhaus, Hamburg, Germany
| | - Tarik Ghadban
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Konrad Reinshagen
- Department of Pediatric Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Michael Boettcher
- Department of Pediatric Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Pogorelić Z, Domjanović J, Jukić M, Poklepović Peričić T. Acute Appendicitis in Children Younger than Five Years of Age: Diagnostic Challenge for Pediatric Surgeons. Surg Infect (Larchmt) 2019; 21:239-245. [PMID: 31618143 DOI: 10.1089/sur.2019.175] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Background: The aim of this study is the evaluation of clinical signs and outcomes of treatment in children under five years of age who underwent appendectomy because of acute appendicitis. Patients and Methods: From January 2009 until December 2018, 90 patients (54 boys and 36 girls) younger than five years of age, treated with appendectomy because of acute appendicitis, were included in this study. Patients were divided into two groups, depending on the intra-operative finding of non-perforated (Group I; n = 32) or perforated (Group II; n = 58) appendicitis. The groups were compared regarding demographic, clinical, and laboratory data and outcomes of treatment. Results: Of 1687 appendectomies in this period, 90 (5.3%) of them were performed in patients aged five years or younger. There were 58 (64.4%) patients with perforated appendix. Positive correlation between the rate of perforation and the age of patients was found. Perforation rates were significantly higher in younger patients (100%, <1 year; 100%, 1-2 y; 83.3%, 2-3 y; 71.4%, 3-4 y; 78.6%, 4-5 y, and 47.3%, 5 y) (p = 0.037). Vomiting and diarrhea were found more commonly in the group of perforated appendix (p < 0.002, p < 0.001), while constipation was found more often in the patients whose appendix was not perforated (p < 0.001). The median duration of symptoms (48 h vs. 16 h; p < 0.001) and median duration of hospitalization (7.5 d vs. 5 d; p < 0.001) were notably longer for the group of patients with perforated than the group of patients with non-perforated appendix. All complications occurred in the group of perforated appendix with total incidence of 4.4%. Conclusion: The clinical presentation of acute appendicitis for children aged five years or younger is often unusual, and establishing the proper diagnosis is often delayed. Patient age is tied closely to the stage of acute appendicitis, so the youngest patients present with more advanced stages of disease and are at greater risk of perforation. Acute appendicitis should be considered in all cases where a child is having abdominal pain, fever, and diarrhea, which has been shown to be present significantly more often in children with perforated appendix.
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Affiliation(s)
- Zenon Pogorelić
- Department of Pediatric Surgery, University Hospital of Split, Split, Croatia.,University of Split, School of Medicine, Split, Croatia
| | | | - Miro Jukić
- Department of Pediatric Surgery, University Hospital of Split, Split, Croatia
| | - Tina Poklepović Peričić
- Department of Research in Biomedicine and Health, University of Split, School of Medicine, Split, Croatia
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Jiang J, Wu Y, Tang Y, Shen Z, Chen G, Huang Y, Zheng S, Zheng Y, Dong R. A novel nomogram for the differential diagnosis between advanced and early appendicitis in pediatric patients. Biomark Med 2019; 13:1157-1173. [PMID: 31559834 DOI: 10.2217/bmm-2019-0036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aim: To develop a nomogram for differential diagnosis between advanced and early pediatric appendicitis (PA). Patients & methods: We retrospectively studied 669 PA patients. Patient characteristics and 24 serum markers were subjected to univariate and multivariate analysis, based on which the nomogram was constructed. Results: Fibrin degradation product, CRP and Na+ differed significantly between the advanced and early PA. The value of area under the receiver operating characteristic curve (AUC) was 0.8602, which was greater than that of a single serum marker. Furthermore, the nomogram showed better discriminative ability than the biomarker alone. Notably, validation indicated high stability and reproducibility. Conclusion: The nomogram is superior to the serum marker alone, and may hold promise in clinical application.
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Affiliation(s)
- Jingying Jiang
- Department of Pediatric Surgery, Children's Hospital of Fudan University, Shanghai Key Laboratory of Birth Defect, Shanghai 201102, PR China
| | - Ying Wu
- Department of Pediatric Surgery, Children's Hospital of Fudan University, Shanghai Key Laboratory of Birth Defect, Shanghai 201102, PR China
| | - Yue Tang
- Department of Pediatric Surgery, Children's Hospital of Fudan University, Shanghai Key Laboratory of Birth Defect, Shanghai 201102, PR China
| | - Zhen Shen
- Department of Pediatric Surgery, Children's Hospital of Fudan University, Shanghai Key Laboratory of Birth Defect, Shanghai 201102, PR China
| | - Gong Chen
- Department of Pediatric Surgery, Children's Hospital of Fudan University, Shanghai Key Laboratory of Birth Defect, Shanghai 201102, PR China
| | - Yanlei Huang
- Department of Pediatric Surgery, Children's Hospital of Fudan University, Shanghai Key Laboratory of Birth Defect, Shanghai 201102, PR China
| | - Shan Zheng
- Department of Pediatric Surgery, Children's Hospital of Fudan University, Shanghai Key Laboratory of Birth Defect, Shanghai 201102, PR China
| | - Yijie Zheng
- Department of Medical Scientific Affairs, Wuxi Diagnosis, Wuxi Apptec, Shanghai, PR China
| | - Rui Dong
- Department of Pediatric Surgery, Children's Hospital of Fudan University, Shanghai Key Laboratory of Birth Defect, Shanghai 201102, PR China
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Aneiros B, Cano I, García A, Yuste P, Ferrero E, Gómez A. PEDIATRIC APPENDICITIS: AGE DOES MAKE A DIFFERENCE. ACTA ACUST UNITED AC 2019; 37:318-324. [PMID: 31241690 PMCID: PMC6868550 DOI: 10.1590/1984-0462/;2019;37;3;00019] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2018] [Accepted: 04/29/2018] [Indexed: 01/16/2023]
Abstract
Objective: To investigate the influence of patient age on the diagnosis and management
of appendicitis, as well as to evaluate the rate of complications according
to the age group. Methods: We undertook a retrospective analysis of 1,736 children who underwent
laparoscopic appendectomy in our center between January 2000 and December
2013. Patients were divided in groups taken into account their age: group A
were infants, group B were preschoolers, group C were those ones older than
five years old, and group D were those ones younger than five years old. A p
value of 0.05 was considered statistically significant. Results: We found higher incidence of misdiagnosis and atypical symptoms in the
youngest patients. The rate of perforation was similar between group A and B
(p=0.17). However, it was higher in group D than in group C (p<0.0001).
The incidence of postoperative complications was higher in the youngest
patients too (p=0.0002). Conclusions: The age does make a difference in acute appendicitis. Because of its unusual
presentation in children younger than five years old, it is often
misdiagnosed, which leads to an increased morbidity. Although clinical
presentation varies between infants and preschoolers, no statistically
significant differences were observed in the rate of perforated appendix or
postoperative complications.
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Abstract
RATIONALE Acute appendicitis is one of the most common causes of acute abdomen in children, yet it is difficult to diagnose in young children because its clinical manifestations may be atypical. Here, 3 atypical clinical cases associated with appendicitis in children are reported. PATIENT CONCERN The 1st case corresponds to a 5-year-old male patient who presented with abdominal discomfort, intermittent fevers, and vomiting, have increased white blood cell (WBC) count and C-reactive protein (CRP). The second case is a 7-year-old male patient who began with intermittent fevers and lower quadrant abdominal pain, showing increased WBC count and CRP. The 3rd case corresponds to a 7-year-old female patient who presented with intermittent fevers, abdominal pain, and forebreast discomfort, demonstrating increased WBC count and CRP. DIAGNOSES Abdominal computed tomography (CT) scan presented data suggestive of enlarged appendix in diameter, and stercolith, corroborated through surgery. INTERVENTION Two patients were treated by appendectomy, and 1 patient was treated conservatively with antibiotics. OUTCOMES Three patients were treated successfully. At 3-month follow-up, the patients had no complaints of discomfort with no relapse of appendicitis. LESSONS Due to atypical symptoms of children, the diagnosis of appendicitis is often delayed, suggesting that the clinicians should be aware of this disease when encountering gastroenteritis patients with elevated WBC and CRP. Furthermore, abdominal CT scan should be taken into consideration when patients showed high level of WBC and CRP, whose appendix is not seen on ultrasound.
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Affiliation(s)
- Zhi-hua Wang
- Department of Pediatrics, Integrated Traditional Chinese and Western Medicine, Tianjin Nankai Hospital
| | - Jing Ye
- Department of Pediatrics, Integrated Traditional Chinese and Western Medicine, Tianjin Nankai Hospital
- Department of Pediatrics, The Second Hospital Affiliated to Tianjin Medical University, Tianjin, China
| | - Yu-shui Wang
- Department of Pediatrics, Integrated Traditional Chinese and Western Medicine, Tianjin Nankai Hospital
| | - Yan Liu
- Department of Pediatrics, Integrated Traditional Chinese and Western Medicine, Tianjin Nankai Hospital
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Faraji‐Goodarzi M. Sepsis after non-perforated acute appendicitis. Clin Case Rep 2019; 7:520-523. [PMID: 30899485 PMCID: PMC6406223 DOI: 10.1002/ccr3.2030] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Revised: 01/07/2019] [Accepted: 01/15/2019] [Indexed: 12/15/2022] Open
Abstract
Appendicitis is a worm-like appendage whose base is located on the posterior side of the inner cecum. Acute appendicitis is uncommon in children younger than 5 years old. The patient was a 1.5-year-old boy who was admitted to the hospital with a primary complaint of fever, diarrhea, and vomiting. A pathological report of acute puffiness appendicitis with peri appendicitis was confirmed. After two weeks of treatment, the patient was discharged with an good general condition.
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Affiliation(s)
- Mojgan Faraji‐Goodarzi
- Faculty of Medicine, Department of PediatricsLorestan University of Medical SciencesKhorramabadIran
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58
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Mushtaq R, Desoky SM, Morello F, Gilbertson-Dahdal D, Gopalakrishnan G, Leetch A, Vedantham S, Kalb B, Martin DR, Udayasankar UK. First-Line Diagnostic Evaluation with MRI of Children Suspected of Having Acute Appendicitis. Radiology 2019; 291:170-177. [PMID: 30747595 DOI: 10.1148/radiol.2019181959] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Background Advances in abdominal MRI have enabled rapid, free-breathing imaging without the need for intravenous or oral contrast material. The use of MRI as the primary imaging modality for suspected appendicitis has not been previously studied. Purpose To determine the diagnostic performance of MRI as the initial imaging modality in children suspected of having acute appendicitis. Materials and Methods The study included consecutive patients 18 years of age and younger presenting with acute abdominal pain at a tertiary care institution from January 2013 through June 2016 who subsequently underwent an unenhanced MRI examination as the primary diagnostic imaging modality. Electronic medical records and radiology reports were retrospectively evaluated for the feasibility and diagnostic performance of MRI, with surgical pathology and follow-up electronic records as reference standards. Statistical analyses were performed by using simple binomial proportions to quantify sensitivity, specificity, and accuracy, and exact 95% confidence intervals (CIs) were obtained. Results After exclusions, 402 patients (median age: 13 years; interquartile range [IQR], 9-15 years; 235 female patients; 167 male patients) were included. Sedation for MRI was required in 13 of 402 patients (3.2%; 95% CI: 1.7%, 5.5%). The appendix was visualized in 349 of 402 patients (86.8%; 95% CI: 83.1%, 90%); for the remaining patients, a diagnosis was provided on the basis of secondary signs of appendicitis. The sensitivity, specificity, and accuracy of MRI as the primary diagnostic imaging modality for the evaluation of acute appendicitis were 97.9% (95 of 97; 95% CI: 92.8%, 99.8%), 99% (302 of 305; 95% CI: 97.2%, 99.8%), and 98.8% (397 of 402; 97.1%, 99.6%), respectively. Among patients with negative findings for appendicitis at MRI, an alternate diagnosis was provided in 113 of 304 patients (37.2%; 95% CI: 31.7%, 42.9%). Conclusion When performed as the initial imaging modality in children suspected of having acute appendicitis, MRI examinations had high diagnostic performance for the diagnosis of acute appendicitis and in providing alternative diagnoses. © RSNA, 2019 See also the editorial by Dillman and Trout in this issue.
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Affiliation(s)
- Raza Mushtaq
- From the Departments of Medical Imaging (R.M., S.M.D., F.M., D.G., S.V., B.K., D.R.M., U.K.U.), Pediatrics (G.G.), and Pediatric Emergency Medicine (A.L.), University of Arizona College of Medicine, 1501 N Campbell Ave, Tucson, AZ 85724
| | - Sarah M Desoky
- From the Departments of Medical Imaging (R.M., S.M.D., F.M., D.G., S.V., B.K., D.R.M., U.K.U.), Pediatrics (G.G.), and Pediatric Emergency Medicine (A.L.), University of Arizona College of Medicine, 1501 N Campbell Ave, Tucson, AZ 85724
| | - Frank Morello
- From the Departments of Medical Imaging (R.M., S.M.D., F.M., D.G., S.V., B.K., D.R.M., U.K.U.), Pediatrics (G.G.), and Pediatric Emergency Medicine (A.L.), University of Arizona College of Medicine, 1501 N Campbell Ave, Tucson, AZ 85724
| | - Dorothy Gilbertson-Dahdal
- From the Departments of Medical Imaging (R.M., S.M.D., F.M., D.G., S.V., B.K., D.R.M., U.K.U.), Pediatrics (G.G.), and Pediatric Emergency Medicine (A.L.), University of Arizona College of Medicine, 1501 N Campbell Ave, Tucson, AZ 85724
| | - Geetha Gopalakrishnan
- From the Departments of Medical Imaging (R.M., S.M.D., F.M., D.G., S.V., B.K., D.R.M., U.K.U.), Pediatrics (G.G.), and Pediatric Emergency Medicine (A.L.), University of Arizona College of Medicine, 1501 N Campbell Ave, Tucson, AZ 85724
| | - Aaron Leetch
- From the Departments of Medical Imaging (R.M., S.M.D., F.M., D.G., S.V., B.K., D.R.M., U.K.U.), Pediatrics (G.G.), and Pediatric Emergency Medicine (A.L.), University of Arizona College of Medicine, 1501 N Campbell Ave, Tucson, AZ 85724
| | - Srinivasan Vedantham
- From the Departments of Medical Imaging (R.M., S.M.D., F.M., D.G., S.V., B.K., D.R.M., U.K.U.), Pediatrics (G.G.), and Pediatric Emergency Medicine (A.L.), University of Arizona College of Medicine, 1501 N Campbell Ave, Tucson, AZ 85724
| | - Bobby Kalb
- From the Departments of Medical Imaging (R.M., S.M.D., F.M., D.G., S.V., B.K., D.R.M., U.K.U.), Pediatrics (G.G.), and Pediatric Emergency Medicine (A.L.), University of Arizona College of Medicine, 1501 N Campbell Ave, Tucson, AZ 85724
| | - Diego R Martin
- From the Departments of Medical Imaging (R.M., S.M.D., F.M., D.G., S.V., B.K., D.R.M., U.K.U.), Pediatrics (G.G.), and Pediatric Emergency Medicine (A.L.), University of Arizona College of Medicine, 1501 N Campbell Ave, Tucson, AZ 85724
| | - Unni K Udayasankar
- From the Departments of Medical Imaging (R.M., S.M.D., F.M., D.G., S.V., B.K., D.R.M., U.K.U.), Pediatrics (G.G.), and Pediatric Emergency Medicine (A.L.), University of Arizona College of Medicine, 1501 N Campbell Ave, Tucson, AZ 85724
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Reddan T, Corness J, Harden F, Mengersen K. Paediatric appendiceal ultrasound: a survey of Australasian sonographers' opinions on examination performance and sonographic criteria. J Med Radiat Sci 2018; 65:267-274. [PMID: 30370623 PMCID: PMC6275268 DOI: 10.1002/jmrs.310] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Revised: 10/03/2018] [Accepted: 10/04/2018] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION The objectives of this study were to identify knowledge gaps and/or perceived limitations in the performance of paediatric appendiceal ultrasound by Australasian sonographers. We hypothesised that: sonographers' confidence in visualising the appendix in children was poor, particularly outside predominantly paediatric practice; workplace support for prolonging examinations to improve visualisation was limited; and the sonographic criteria applied in diagnosis did not reflect contemporary literature. METHODS A cross-sectional survey of Australasian sonographers regarding paediatric appendicitis was conducted using a mixed methods approach (quantitative and qualitative data). Text responses were analysed for key themes, and quantitative data analysed using chi-square, Mann-Whitney U and Wilcoxon signed-rank tests. RESULTS Of the 124 respondents, 27 (21.8%) reported a visualisation rate of less than 10%. Workplace support for extending examination time was significantly related to a higher appendix visualisation rate (χ2 (2) = 16.839, P < 0.001). Text responses reported frustration locating the appendix and a desire for more time and practice to improve visualisation. Sonographers suggested a significantly lower maximum diameter cut-off in a 5-year-old compared to a 13-year-old (Z = -6.07, P < 0.001), and considered the presence of inflamed peri-appendiceal mesentery as the most useful sonographic criterion in diagnosing acute appendicitis. CONCLUSIONS Respondents had a low opinion of their ability to confidently identify the appendix. Confidence was greater in those centres where extending scanning time was encouraged. Application of echogenic mesentery as the most significant secondary sonographic criterion is supported by recent studies. Opinions of diameter cut-offs varied, indicating potential for improved awareness of recent research.
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Affiliation(s)
- Tristan Reddan
- Medical Imaging and Nuclear MedicineLady Cilento Children's HospitalChildren's Health Queensland Hospital and Health ServiceSouth BrisbaneQueenslandAustralia
- Science and Engineering FacultyQueensland University of TechnologyBrisbaneQueenslandAustralia
| | - Jonathan Corness
- Medical Imaging and Nuclear MedicineLady Cilento Children's HospitalChildren's Health Queensland Hospital and Health ServiceSouth BrisbaneQueenslandAustralia
| | - Fiona Harden
- Hunter Industrial MedicineMaitlandNew South WalesAustralia
| | - Kerrie Mengersen
- Science and Engineering FacultyQueensland University of TechnologyBrisbaneQueenslandAustralia
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Eng KA, Abadeh A, Ligocki C, Lee YK, Moineddin R, Adams-Webber T, Schuh S, Doria AS. Acute Appendicitis: A Meta-Analysis of the Diagnostic Accuracy of US, CT, and MRI as Second-Line Imaging Tests after an Initial US. Radiology 2018; 288:717-727. [DOI: 10.1148/radiol.2018180318] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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Moxifloxacin in Pediatric Patients With Complicated Intra-abdominal Infections: Results of the MOXIPEDIA Randomized Controlled Study. Pediatr Infect Dis J 2018; 37:e207-e213. [PMID: 29356761 DOI: 10.1097/inf.0000000000001910] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND This study was designed to evaluate primarily the safety and also the efficacy of moxifloxacin (MXF) in children with complicated intra-abdominal infections (cIAIs). METHODS In this multicenter, randomized, double-blind, controlled study, 451 pediatric patients aged 3 months to 17 years with cIAIs were treated with intravenous/oral MXF (N = 301) or comparator (COMP, intravenous ertapenem followed by oral amoxicillin/clavulanate; N = 150) for 5 to 14 days. Doses of MXF were selected based on the results of a Phase 1 study in pediatric patients (NCT01049022). The primary endpoint was safety, with particular focus on cardiac and musculoskeletal safety; clinical and bacteriologic efficacy at test of cure was also investigated. RESULTS The proportion of patients with adverse events (AEs) was comparable between the 2 treatment arms (MXF: 58.1% and COMP: 54.7%). The incidence of drug-related AEs was higher in the MXF arm than in the COMP arm (14.3% and 6.7%, respectively). No cases of QTc interval prolongation-related morbidity or mortality were observed. The proportion of patients with musculoskeletal AEs was comparable between treatment arms; no drug-related events were reported. Clinical cure rates were 84.6% and 95.5% in the MXF and COMP arms, respectively, in patients with confirmed pathogen(s) at baseline. CONCLUSIONS MXF treatment was well tolerated in children with cIAIs. However, a lower clinical cure rate was observed with MXF treatment compared with COMP. This study does not support a recommendation of MXF for children with cIAIs when alternative more efficacious antibiotics with better safety profile are available.
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Cozzi G, Galdo F, Germani C, Codrich D, Gregori M, Barbi E. Still toddler: A clinical clue for acute appendicitis. J Paediatr Child Health 2018; 54:913-914. [PMID: 29561068 DOI: 10.1111/jpc.13907] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2017] [Revised: 01/31/2018] [Accepted: 02/22/2018] [Indexed: 11/28/2022]
Affiliation(s)
- Giorgio Cozzi
- Institute for Maternal and Child Health, Burlo Garofolo Pediatric Institute, Trieste, Italy
| | - Francesca Galdo
- Department of General and Specialized Surgery for Women and Children, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Claudio Germani
- Institute for Maternal and Child Health, Burlo Garofolo Pediatric Institute, Trieste, Italy
| | - Daniela Codrich
- Institute for Maternal and Child Health, Burlo Garofolo Pediatric Institute, Trieste, Italy
| | - Massimo Gregori
- Institute for Maternal and Child Health, Burlo Garofolo Pediatric Institute, Trieste, Italy
| | - Egidio Barbi
- Institute for Maternal and Child Health, Burlo Garofolo Pediatric Institute, Trieste, Italy
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Rodriguez Zorro A, Vivas Diaz JH. Death caused by appendicular knotting and small-bowel strangulation in a child: A case report and review. MEDICINE, SCIENCE, AND THE LAW 2018; 58:115-118. [PMID: 29433399 DOI: 10.1177/0025802418756780] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Acute appendicitis is one of the most common surgical emergencies in paediatrics. However, acute appendicitis in early infancy is an uncommon condition. Furthermore, strangulation of the small intestine through appendicular knotting is described as very unusual in the literature and is generally not well-diagnosed in the clinical context. This article reports the case of a 23-month-old girl who entered the emergency department with a three-day history of abdominal symptoms and who died in less than 24 hours without receiving surgical intervention. The case turned judicial at the request of the parents who claimed lack of clarity in the diagnosis. A medico-legal autopsy was ordered to clarify the cause and manner of death. The autopsy documented herniation, strangulation and torsion of a 70 cm segment of the jejunum/ileum through an appendicular knot caused by the attachment of the distal end of the inflamed appendage to the ileum. The case is relevant because it is the first case of death by appendicular knot and strangulation of small bowel in an infant reported in the literature. The importance of autopsy to clarify the clinical diagnosis is noted.
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Hamid KA, Mohamed MA, Salih A. Acute Appendicitis in Young Children: A Persistent Diagnostic Challenge for Clinicians. Cureus 2018; 10:e2347. [PMID: 29796359 PMCID: PMC5959314 DOI: 10.7759/cureus.2347] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Acute appendicitis is a grave and life-threatening condition in children, accounting for one to two cases per 10,000 in children less than four years' old. Prompt diagnosis and management are imperative to prevent serious complications, such as abscess formation, perforation, bowel obstruction, peritonitis, and sepsis. In young children, however, the diagnosis of this condition is challenging. The delayed utilization of imaging may further delay the diagnosis due to concerns of exposure to ionizing radiation. Even with a prompt diagnosis, controversy persists regarding medical versus operative management in these young patients. We report a case of a 21-month-old female who presented with fever, non-bilious, non-bloody emesis, and decreased tolerance for liquids and solids. The initial physical exam and imaging were suggestive of non-obstructive bowel distention. The patient was admitted to the pediatric floor. Overnight, the patient’s condition deteriorated severely and became septic. Repeat imaging revealed a 9-cm appendicular mass and a ruptured appendix. Antibiotic coverage was then broadened and the patient was transferred to the critical care unit for more intensive management. The patient’s septic condition improved over the upcoming few days and the parents elected to perform an elective appendectomy following resolution of the condition. Atypical presentations are common in this population. The difficulty in obtaining a reliable history and physical examination findings makes the diagnosis even more challenging. Moreover, concerns with radiation exposure may delay the diagnosis and increase the risk of perforation and peritonitis. Thus, clinicians should have a high index of suspicion for acute appendicitis, particularly in young children, as this condition is commonly missed on initial presentation.
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Affiliation(s)
- Kewan A Hamid
- Department of Combined Internal Medicine-Pediatrics, Hurley Medical Center, Michigan State University College of Human Medicine
| | | | - Anas Salih
- Department of Combined Internal Medicine-Pediatrics, Hurley Medical Center
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Appendiceal outer diameter as an indicator of acute appendicitis in young children. Am J Emerg Med 2018; 36:1899-1900. [PMID: 29428695 DOI: 10.1016/j.ajem.2018.01.102] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Accepted: 01/30/2018] [Indexed: 11/21/2022] Open
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Zouari M, Louati H, Abid I, Ben Abdallah AK, Ben Dhaou M, Jallouli M, Mhiri R. C-reactive protein value is a strong predictor of acute appendicitis in young children. Am J Emerg Med 2017; 36:1319-1320. [PMID: 29217177 DOI: 10.1016/j.ajem.2017.11.067] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Accepted: 11/29/2017] [Indexed: 11/15/2022] Open
Affiliation(s)
- M Zouari
- Department of Pediatric Surgery, Hedi-Chaker Hospital, 3029 Sfax, Tunisia.
| | - H Louati
- Department of Pediatric Surgery, Hedi-Chaker Hospital, 3029 Sfax, Tunisia
| | - I Abid
- Department of Pediatric Surgery, Hedi-Chaker Hospital, 3029 Sfax, Tunisia
| | - A K Ben Abdallah
- Department of Pediatric Surgery, Hedi-Chaker Hospital, 3029 Sfax, Tunisia
| | - M Ben Dhaou
- Department of Pediatric Surgery, Hedi-Chaker Hospital, 3029 Sfax, Tunisia
| | - M Jallouli
- Department of Pediatric Surgery, Hedi-Chaker Hospital, 3029 Sfax, Tunisia
| | - R Mhiri
- Department of Pediatric Surgery, Hedi-Chaker Hospital, 3029 Sfax, Tunisia
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Benabbas R, Hanna M, Shah J, Sinert R. Diagnostic Accuracy of History, Physical Examination, Laboratory Tests, and Point-of-care Ultrasound for Pediatric Acute Appendicitis in the Emergency Department: A Systematic Review and Meta-analysis. Acad Emerg Med 2017; 24:523-551. [PMID: 28214369 DOI: 10.1111/acem.13181] [Citation(s) in RCA: 112] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2016] [Revised: 01/17/2017] [Accepted: 02/06/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND Acute appendicitis (AA) is the most common surgical emergency in children. Accurate and timely diagnosis is crucial but challenging due to atypical presentations and the inherent difficulty of obtaining a reliable history and physical examination in younger children. OBJECTIVES The aim of this study was to determine the utility of history, physical examination, laboratory tests, Pediatric Appendicitis Score (PAS) and Emergency Department Point-of-Care Ultrasound (ED-POCUS) in the diagnosis of AA in ED pediatric patients. We performed a systematic review and meta-analysis and used a test-treatment threshold model to identify diagnostic findings that could rule in/out AA and obviate the need for further imaging studies, specifically computed tomography (CT) scan, magnetic resonance imaging (MRI), and radiology department ultrasound (RUS). METHODS We searched PubMed, EMBASE, and SCOPUS up to October 2016 for studies on ED pediatric patients with abdominal pain. Quality Assessment Tool for Diagnostic Accuracy Studies (QUADAS-2) was used to evaluate the quality and applicability of included studies. Positive and negative likelihood ratios (LR+ and LR-) for diagnostic modalities were calculated and when appropriate data was pooled using Meta-DiSc. Based on the available literature on the test characteristics of different imaging modalities and applying the Pauker-Kassirer method we developed a test-treatment threshold model. RESULTS Twenty-one studies were included encompassing 8,605 patients with weighted AA prevalence of 39.2%. Studies had variable quality using the QUADAS-2 tool with most studies at high risk of partial verification bias. We divided studies based on their inclusion criteria into two groups of "undifferentiated abdominal pain" and abdominal pain "suspected of AA." In patients with undifferentiated abdominal pain, history of "pain migration to right lower quadrant (RLQ)" (LR+ = 4.81, 95% confidence interval [CI] = 3.59-6.44) and presence of "cough/hop pain" in the physical examination (LR+ = 7.64, 95% CI = 5.94-9.83) were most strongly associated with AA. In patients suspected of AA none of the history or laboratory findings were strongly associated with AA. Rovsing's sign was the physical examination finding most strongly associated with AA (LR+ = 3.52, 95% CI = 2.65-4.68). Among different PAS cutoff points, PAS ≥ 9 (LR+ = 5.26, 95% CI = 3.34-8.29) was most associated with AA. None of the history, physical examination, laboratory tests findings, or PAS alone could rule in or rule out AA in patients with undifferentiated abdominal pain or those suspected of AA. ED-POCUS had LR+ of 9.24 (95% CI = 6.24-13.28) and LR- of 0.17 (95% CI = 0.09-0.30). Using our test-treatment threshold model, positive ED-POCUS could rule in AA without the use of CT and MRI, but negative ED-POCUS could not rule out AA. CONCLUSION Presence of AA is more likely in patients with undifferentiated abdominal pain migrating to the RLQ or when cough/hop pain is present in the physical examination. Once AA is suspected, no single history, physical examination, laboratory finding, or score attained on PAS can eliminate the need for imaging studies. Operating characteristics of ED-POCUS are similar to those reported for RUS in literature for diagnosis of AA. In ED patients suspected of AA, a positive ED-POCUS is diagnostic and obviates the need for CT or MRI while negative ED-POCUS is not enough to rule out AA.
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Affiliation(s)
- Roshanak Benabbas
- Department of Emergency Medicine; State University of New York/SUNY Downstate Medical Center; Brooklyn NY
- Department of Emergency Medicine; Kings County Hospital Center; Brooklyn NY
| | - Mark Hanna
- Department of Pediatrics; State University of New York/SUNY Downstate Medical Center; Brooklyn NY
- Department of Pediatrics; Kings County Hospital Center; Brooklyn NY
| | - Jay Shah
- Department of Emergency Medicine; Kings County Hospital Center; Brooklyn NY
| | - Richard Sinert
- Department of Emergency Medicine; State University of New York/SUNY Downstate Medical Center; Brooklyn NY
- Department of Emergency Medicine; Kings County Hospital Center; Brooklyn NY
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69
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Caruso AM, Pane A, Garau R, Atzori P, Podda M, Casuccio A, Mascia L. Acute appendicitis in children: not only surgical treatment. J Pediatr Surg 2017; 52:444-448. [PMID: 27612631 DOI: 10.1016/j.jpedsurg.2016.08.007] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2016] [Revised: 07/28/2016] [Accepted: 08/13/2016] [Indexed: 12/26/2022]
Abstract
PURPOSE An accurate diagnosis of acute appendicitis is important to avoid severe outcome or unnecessary surgery but management is controversial. The aim of study was to evaluate, in younger and older children, the efficacy of conservative management for uncomplicated appendicitis and the outcome of complicated forms underwent early surgery. METHODS Children with acute appendicitis were investigated by clinical, laboratory variables and abdominal ultrasound and divided in two groups: complicated and uncomplicated. Complicated appendicitis underwent early surgery; uncomplicated appendicitis started conservative treatment with antibiotic. If in the next 24-48h it was worsening, the conservative approach failed and patients underwent late surgery. RESULTS A total of 362 pediatric patients were included. One hundred sixty-five underwent early appendectomy; 197 patients were at first treated conservatively: of these, 82 were operated within 24-48h for failure. The total percentage of operated patients was 68.2%. An elevated association was found between surgery and ultrasound. CONCLUSIONS Conservative treatment for uncomplicated appendicitis had high percentage of success (58%). Complications in operated patients were infrequent. Our protocol was effective in order to decide which patients treat early surgically and which conservatively; specific red flags (age and onset) can identified patients at most risk of complications or conservative failure. TYPE OF STUDY treatment study. LEVEL OF EVIDENCE II.
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Affiliation(s)
| | - Alessandro Pane
- Pediatric Surgical Unit, SS Trinità Hospital, Cagliari, Italy
| | - Roberto Garau
- Pediatric Surgical Unit, SS Trinità Hospital, Cagliari, Italy
| | - Pietro Atzori
- Pediatric Surgical Unit, SS Trinità Hospital, Cagliari, Italy
| | - Marcello Podda
- Pediatric Surgical Unit, SS Trinità Hospital, Cagliari, Italy
| | | | - Luigi Mascia
- Pediatric Surgical Unit, SS Trinità Hospital, Cagliari, Italy
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Guanà R, Lonati L, Garofalo S, Tommasoni N, Ferrero L, Cerrina A, Lemini R, Dallan C, Schleef J. Laparoscopic versus Open Surgery in Complicated Appendicitis in Children Less Than 5 Years Old: A Six-Year Single-Centre Experience. Surg Res Pract 2016; 2016:4120214. [PMID: 27747272 PMCID: PMC5055972 DOI: 10.1155/2016/4120214] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2016] [Revised: 08/05/2016] [Accepted: 08/08/2016] [Indexed: 12/29/2022] Open
Abstract
Introduction. Acute appendicitis is the most common surgical emergency in the pediatric population. The peak incidence occurs in the first decade of life, while it is uncommon to face appendicitis in children younger than 5 years of age. Laparoscopy is now demonstrated to be the optimal approach also to treat complicated appendicitis, but in very young children this standardized operation is not always easy to perform. Material and Methods. From January 2009 to December 2015 we operated on 525 acute appendicitis, with 120 patients less than 5 years of age. Results. 90 children had a complicated appendicitis (localized or diffuse peritonitis): 43 (48%) were operated on by open approach and 47 (52%) by laparoscopy. The overall incidence of postoperative complications was greater in the open appendectomy group (63% versus 26%) and all severe complications requiring reintervention (6% of cases: 3 postoperative abscesses resolved with ultrasound guided percutaneous abscess drainage; 1 tubal surgery for salpingitis; 1 adhesion-related ileus requiring relaparotomy) were mostly associated with open surgery. Conclusions. Laparoscopic surgery resulted as the best approach for treating complicated appendicitis also in younger children, with minor and less severe postoperative complications compared to open surgery.
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Affiliation(s)
- R. Guanà
- Division of Pediatric General, Thoracic & Minimally Invasive Surgery, AOU Città della Salute e della Scienza, Regina Margherita Children's Hospital, Turin, Italy
| | - L. Lonati
- Division of Pediatric General, Thoracic & Minimally Invasive Surgery, AOU Città della Salute e della Scienza, Regina Margherita Children's Hospital, Turin, Italy
| | - S. Garofalo
- Division of Pediatric General, Thoracic & Minimally Invasive Surgery, AOU Città della Salute e della Scienza, Regina Margherita Children's Hospital, Turin, Italy
| | - N. Tommasoni
- Division of Pediatric General, Thoracic & Minimally Invasive Surgery, AOU Città della Salute e della Scienza, Regina Margherita Children's Hospital, Turin, Italy
| | - L. Ferrero
- Division of Pediatric General, Thoracic & Minimally Invasive Surgery, AOU Città della Salute e della Scienza, Regina Margherita Children's Hospital, Turin, Italy
| | - A. Cerrina
- Division of Pediatric General, Thoracic & Minimally Invasive Surgery, AOU Città della Salute e della Scienza, Regina Margherita Children's Hospital, Turin, Italy
| | - R. Lemini
- Division of Pediatric General, Thoracic & Minimally Invasive Surgery, AOU Città della Salute e della Scienza, Regina Margherita Children's Hospital, Turin, Italy
| | - C. Dallan
- Division of Pediatric General, Thoracic & Minimally Invasive Surgery, AOU Città della Salute e della Scienza, Regina Margherita Children's Hospital, Turin, Italy
| | - J. Schleef
- Division of Pediatric General, Thoracic & Minimally Invasive Surgery, AOU Città della Salute e della Scienza, Regina Margherita Children's Hospital, Turin, Italy
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Campylobacter jejuni-assoziierte Gastroenteritis und akute Appendizitis: zwei Kasuistiken. Monatsschr Kinderheilkd 2016. [DOI: 10.1007/s00112-016-0076-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Kim Y, Jung K, Ryu YJ, Moon SB. Pediatric appendectomy: the outcome differences between pediatric surgeons and general surgeons. Surg Today 2016; 46:1181-6. [PMID: 27142973 DOI: 10.1007/s00595-016-1343-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2015] [Accepted: 11/19/2015] [Indexed: 11/28/2022]
Abstract
PURPOSE The aim of this study was to review our experience of pediatric appendectomy performed by either a general surgeon (GS) or a pediatric surgeon (PS) to determine any differences in outcomes. METHODS We reviewed the medical records of pediatric appendicitis patients, 4 years before (GS group, 2007-2010) and after (PS group, 2011-2014) the introduction of a pediatric surgical practice. The records were reviewed for the following variables: operation time, length of hospital stay, complications, readmission in ≤30 days, type of operation, negative for appendicitis, drainage, open conversion, and reoperation in ≤30 days. RESULTS Over 8 years, 400 patients were operated on for acute appendicitis, with the PS group comprising 61 % (N = 244) of patients. The operation time (55.1 vs 43.2 min, p = 0.0001) and postoperative length of hospital stay (3.5 vs 2.7 days, p = 0.001) were shorter, more patients were treated by laparoscopy (61.3 vs 91.2 %, p = 0.0001), and a fewer patients required peritoneal drainage (29.5 vs 63.2 %, p = 0.023) in the PS group than in the GS group. The negative appendectomy rate was slightly lower in the PS group, but not to a statistically significant degree. CONCLUSION The patients in the PS group enjoyed a reduced operation time and length of hospital stay, greater likelihood of laparoscopic operation, and less peritoneal drainage than the patients in the GS group.
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Affiliation(s)
- Younglim Kim
- Department of Surgery, Kangwon National University School of Medicine, Chuncheon, 200-722, South Korea
| | - Kyuwhan Jung
- Department of Surgery, Seoul National University Bundang Hospital, Songnam, South Korea
| | - Young-Joon Ryu
- Department of Pathology, Kangwon National University School of Medicine, Chuncheon, South Korea
| | - Suk-Bae Moon
- Department of Surgery, Kangwon National University School of Medicine, Chuncheon, 200-722, South Korea.
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Bibalo C, Apicella A, Guastalla V, Marzuillo P, Zennaro F, Tringali C, Taddio A, Germani C, Barbi E. Acute lobar nephritis in children: Not so easy to recognize and manage. World J Clin Pediatr 2016; 5:136-142. [PMID: 26862513 PMCID: PMC4737688 DOI: 10.5409/wjcp.v5.i1.136] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2015] [Revised: 11/17/2015] [Accepted: 12/17/2015] [Indexed: 02/06/2023] Open
Abstract
Acute lobar nephritis (ALN) is a localized non-liquefactive inflammatory renal bacterial infection, which typically involves one or more lobes. ALN is considered to be a midpoint in the spectrum of upper urinary tract infection, a spectrum ranging from uncomplicated pyelonephritis to intrarenal abscess. This condition may be difficult to recognize due to the lack of specific symptoms and laboratory findings. Therefore the disease is probably underdiagnosed. Computed tomography scanning represents the diagnostic gold standard for ALN, but magnetic resonance imagine could be considered in order to limit irradiation. The diagnosis is relevant since initial intravenous antibiotic therapy and overall length of treatment should not be shorter than 3 wk. We review the literature and analyze the ALN clinical presentation starting from four cases with the aim to give to the clinicians the elements to suspect and recognize the ALN in children.
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