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Vevaud K, Dallocchio A, Dumoitier N, Laspougeas A, Labrunie A, Belgacem A, Fourcade L, Ballouhey Q. A prospective study to evaluate the contribution of the pediatric appendicitis score in the decision process. BMC Pediatr 2024; 24:131. [PMID: 38373918 PMCID: PMC10875762 DOI: 10.1186/s12887-024-04619-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Accepted: 02/03/2024] [Indexed: 02/21/2024] Open
Abstract
BACKGROUND The objective of this study was to assess the likelihood of acute appendicitis (AA) in children presenting with abdominal symptoms at the emergency department (ED), based on their prior primary care (PC) consultation history. METHODS Between February and June 2021, we prospectively enrolled all children presenting at the ED with acute abdominal pain indicative of possible acute appendicitis (AA). Subsequently, they were categorized into three groups: those assessed by a PC physician (PG), those brought in by their family without a prior consultation (FG), and those admitted after a PC consultation without being assessed as such. The primary objective was to assess the probability of AA diagnosis using the Pediatric Appendicitis Score (PAS). Secondary objectives included analyzing PAS and C-reactive protein (CRP) levels based on the duration of pain and final diagnoses. RESULTS 124 children were enrolled in the study (PG, n = 56; FG, n = 55; NG, n = 13). Among them, 29 patients (23.4%) were diagnosed with AA, with 13 cases (23.2%) from the PG and 14 cases (25.4%) from the FG. The mean PAS scores for AA cases from the PG and FG were 6.69 ± 1.75 and 7.57 ± 1.6, respectively, (p = 0.3340). Both PAS scores and CRP levels showed a significant correlation with AA severity. No cases of AA were observed with PAS scores < 4. CONCLUSIONS There was no significant difference in PAS scores between patients addressed by PG and FG, even though PAS scores tended to be higher for patients with AA. We propose a new decision-making algorithm for PC practice, which incorporates inflammatory markers and pain duration. TRIAL REGISTRATION Institutional Ethics Committee registration number: 447-2021-103 (10/01/2021). CLINICAL TRIALS REGISTRATION NUMBER ClinicalTrials.gov Identifier: NCT04885335 (Registered on 13/05/2021).
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Affiliation(s)
- Kevin Vevaud
- Service de chirurgie pédiatrique, Hôpital des Enfants, Hôpital Universitaire de Limoges, 8 Avenue Dominique Larrey, Limoges Cedex, 87042, France
| | - Aymeric Dallocchio
- Service de chirurgie pédiatrique, Hôpital des Enfants, Hôpital Universitaire de Limoges, 8 Avenue Dominique Larrey, Limoges Cedex, 87042, France
| | - Nathalie Dumoitier
- Département universitaire de médecine Générale, Faculté de médecine de Limoges, 2 rue du Docteur Marcland, Limoges Cedex, 87042, France
| | - Alban Laspougeas
- Service de chirurgie pédiatrique, Hôpital des Enfants, Hôpital Universitaire de Limoges, 8 Avenue Dominique Larrey, Limoges Cedex, 87042, France
| | - Anaïs Labrunie
- Biostatistics and Research Methodology (CEBIMER), Limoges University Hospital, 2 rue du Docteur Marcland, Limoges Cedex, 87042, France
| | - Alexis Belgacem
- Service de chirurgie pédiatrique, Hôpital des Enfants, Hôpital Universitaire de Limoges, 8 Avenue Dominique Larrey, Limoges Cedex, 87042, France
| | - Laurent Fourcade
- Service de chirurgie pédiatrique, Hôpital des Enfants, Hôpital Universitaire de Limoges, 8 Avenue Dominique Larrey, Limoges Cedex, 87042, France
| | - Quentin Ballouhey
- Service de chirurgie pédiatrique, Hôpital des Enfants, Hôpital Universitaire de Limoges, 8 Avenue Dominique Larrey, Limoges Cedex, 87042, France.
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Zülfikaroğlu B, Akkurt G, Akın M, İşman FK, Yastı AÇ, Özmen MM. Role of serum levels of tumour necrosis factor-like weak inducer of apoptosis (TWEAK) in predicting severity of acute appendicitis. Turk J Surg 2023; 39:121-127. [PMID: 38026909 PMCID: PMC10681112 DOI: 10.47717/turkjsurg.2023.5747] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 03/23/2023] [Indexed: 12/01/2023]
Abstract
Objectives One of the most prevalent abdominal crises is acute appendicitis (AA). Clinical diagnosis, even for skilled surgeons, is frequently challenging, as indicated by the high proportion of negative investigations. The purpose of this study was to see if serum TWEAK levels might be used to diagnose acute appendicitis. Material and Methods Between June 2017 and May 2019, all patients who had surgery with the original diagnosis of AA were included in the study. TWEAK, WBC, CRP, and bilirubin levels were compared. Results The levels of WBC, CRP, and bilirubin were compared to pathology. All three blood indicators increased significantly in AA patients. However, no statistically significant difference in the levels of all three blood indicators was seen between individuals with simple AA and those with severe AA. TWEAK plasma concentrations were considerably greater in patients with severe AA than in the healthy control and NAA groups. TWEAK levels were significantly greater in individuals with severe AA compared to patients with simple AA. Conclusion Serum TWEAK levels that are elevated may be used to diagnose acute appendicitis as well as prognostic indicators for the severity of appendicitis.
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Affiliation(s)
- Barış Zülfikaroğlu
- Clinic of General Surgery, Ankara Numune Training and Research Hospital, Ankara, Türkiye
| | - Gökhan Akkurt
- Clinic of General Surgery, Ankara Numune Training and Research Hospital, Ankara, Türkiye
| | - Merve Akın
- Clinic of General Surgery, Ankara Numune Training and Research Hospital, Ankara, Türkiye
| | - Ferruh Kemal İşman
- Clinic of Clinical Chemistry, Göztepe Training and Research Hospital, İstanbul, Türkiye
| | - Ahmet Çınar Yastı
- Clinic of General Surgery, Ankara Numune Training and Research Hospital, Ankara, Türkiye
| | - Mehmet Mahir Özmen
- Department of Surgery, İstinye University Faculty of Medicine, İstanbul, Türkiye
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Calarco S, Fernandez-Carballo BL, Keller T, Weber S, Jakobi M, Marsall P, Schneiderhan-Marra N, Dittrich S. Analytical performance of 17 commercially available point-of-care tests for CRP to support patient management at lower levels of the health system. PLoS One 2023; 18:e0267516. [PMID: 36662693 PMCID: PMC9858008 DOI: 10.1371/journal.pone.0267516] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Accepted: 01/02/2023] [Indexed: 01/21/2023] Open
Abstract
Accurate and precise point-of-care (POC) testing for C-reactive protein (CRP) can help support healthcare providers in the clinical management of patients. Here, we compared the analytical performance of 17 commercially available POC CRP tests to enable more decentralized use of the tool. The following CRP tests were evaluated. Eight quantitative tests: QuikRead go (Aidian), INCLIX (Sugentech), Spinit (Biosurfit), LS4000 (Lansionbio), GS 1200 (Gensure Biotech), Standard F200 (SD Biosensor), Epithod 616 (DxGen), IFP-3000 (Xincheng Biological); and nine semi-quantitative tests: Actim CRP (ACTIM), NADAL Dipstick (nal von minden), NADAL cassette (nal von minden), ALLTEST Dipstick (Hangzhou Alltest Biotech), ALLTEST Cassette cut-off 10-40-80 (Hangzhou Alltest Biotech), ALLTEST Cassette cut-off 10-30 (Hangzhou Alltest Biotech), Biotest (Hangzhou Biotest Biotech), BTNX Quad Line (BTNX), BTNX Tri Line (BTNX). Stored samples (n = 660) had previously been tested for CRP using Cobas 8000 Modular analyzer (Roche Diagnostics International AG, Rotkreuz, Switzerland (reference standards). CRP values represented the clinically relevant range (10-100 mg/L) and were grouped into four categories (<10 mg/L, 10-40 mg/L or 10-30 mg/L, 40-80 mg/L or 30-80 mg/L, and > 80mg/L) for majority of the semi-quantitative tests. Among the eight quantitative POC tests evaluated, QuikRead go and Spinit exhibited better agreement with the reference method, showing slopes of 0.963 and 0.921, respectively. Semi-quantitative tests with the four categories showed a poor percentage agreement for the intermediate categories and higher percentage agreement for the lower and upper limit categories. Analytical performance varied considerably for the semi-quantitative tests, especially among the different categories of CRP values. Our findings suggest that quantitative tests might represent the best choice for a variety of use cases, as they can be used across a broad range of CRP categories.
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Affiliation(s)
| | | | | | | | - Meike Jakobi
- NMI Natural and Medical Sciences Institute at the University of Tübingen, Reutlingen, Germany
| | - Patrick Marsall
- NMI Natural and Medical Sciences Institute at the University of Tübingen, Reutlingen, Germany
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4
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Blok GCGH, Nikkels ED, van der Lei J, Berger MY, Holtman GA. Added value of CRP to clinical features when assessing appendicitis in children. Eur J Gen Pract 2022; 28:95-101. [PMID: 35535699 PMCID: PMC9103685 DOI: 10.1080/13814788.2022.2067142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 03/10/2022] [Accepted: 04/06/2022] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND The diagnostic value of C-reactive protein (CRP) for appendicitis in children has not been evaluated in primary care. As biochemical responses and differential diagnoses vary with age, separate evaluation in children and adults is needed. OBJECTIVES To determine whether adding CRP to symptoms and signs improves the diagnosis of appendicitis in children with acute abdominal pain in primary care. METHODS A retrospective cohort study in Dutch general practice. Data was collected from the Integrated Primary Care Information database between 2010 and 2016. We included children aged 4-18 years, with no history of appendicitis, presenting with acute abdominal pain, and having a CRP test. Initial CRP levels were related to the specialist's diagnosis of appendicitis, and the test's characteristics were calculated for multiple cut-offs. The value of adding CRP to signs and symptoms was analysed by logistic regression. RESULTS We identified 1076 eligible children, among whom 203 were referred for specialist evaluation and 70 had appendicitis. The sensitivity and specificity of a CRP cut-off ≥10 mg/L were 0.87 (95%CI, 0.77-0.94) and 0.77 (95%CI, 0.74-0.79), respectively. When symptoms lasted > 48 h, this sensitivity increased to 1.00. Positive predictive values for CRP alone were low (0.18-0.38) for all cut-off values (6-100 mg/L). Adding CRP increased the area under the curve from 0.82 (95%CI, 0.78-0.87) to 0.88 (95%CI, 0.84-0.91), and decision curve analysis confirmed that its addition provided the highest net benefit. CONCLUSION CRP adds value to history and physical examination when diagnosing appendicitis in children presenting acute abdominal pain in primary care. Appendicitis is least likely if the CRP value is < 10 mg/L and symptoms have been present for > 48 h.
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Affiliation(s)
- Guus C. G. H. Blok
- Department of General Practice and Elderly Care Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Eelke D. Nikkels
- Department of General Practice and Elderly Care Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Johan van der Lei
- Department of Medical Informatics, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Marjolein Y. Berger
- Department of General Practice and Elderly Care Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Gea A. Holtman
- Department of General Practice and Elderly Care Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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Haider Kazmi SJ, Tabassum S, Asghar MS, Siddiqui MA, Avinash, Yasmin F, Tahir MJ, Aziz Y, Kirmani TA, Ahmed M. Role of inflammatory and hematological markers in predicting the complicated and perforated acute appendicitis in pediatric population: A cohort study. Ann Med Surg (Lond) 2022; 76:103524. [PMID: 35495380 PMCID: PMC9052133 DOI: 10.1016/j.amsu.2022.103524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Revised: 03/20/2022] [Accepted: 03/26/2022] [Indexed: 11/24/2022] Open
Abstract
Introduction Methods Results Conclusion Evaluation of inflammatory markers is considered helpful in the diagnosis of acute appendicitis. C-Reactive Protein (CRP) is considered one of the most important inflammatory markers. CRP was helpful not only as an independent marker of severity in acute appendicitis but also predicting complications and perforation as well with higher sensitivity. CRP has the highest specificity for complicated appendicitis and the highest positive likelihood ratio for perforated appendicitis.
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Asakawa M, Fukuzawa M, Asakawa MG, Flanders JA. Preoperative serum C-reactive protein concentration can be used to detect gallbladder rupture in dogs with gallbladder mucocele. Am J Vet Res 2022; 83:23-32. [PMID: 34757924 DOI: 10.2460/ajvr.21.09.0141] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVE To determine whether serum C-reactive protein (CRP) concentration could be used to detect gallbladder rupture (GBR) prior to surgery in dogs undergoing cholecystectomy for treatment of gallbladder mucocele (GBM). ANIMALS 45 dogs that underwent cholecystectomy because of GBM at a companion animal referral hospital from 2017 to 2020. PROCEDURES Electronic medical records were reviewed, and dogs were included if serum CRP concentration had been measured within 24 hours prior to cholecystectomy. Dogs were grouped as to whether the gallbladder was found to be ruptured or intact during surgery. Accuracy of using preoperative CRP concentration to predict GBR was compared with accuracy of abdominal ultrasonography and other preoperative blood tests. RESULTS GBR was present in 15 dogs at the time of surgery. Median preoperative CRP concentration was significantly higher in dogs with GBR (15.1 mg/dL; interquartile range, 7.4 to 16.8 mg/dL) than in dogs with an intact gallbladder (2.65 mg/dL; interquartile range, 0.97 to 13.4 mg/dL). Sensitivity, specificity, and accuracy of using preoperative CRP concentration to predict GBR were 100%, 67%, and 78%, respectively. CLINICAL RELEVANCE Measurement of preoperative CRP concentration provided excellent sensitivity and moderate specificity for detection of GBR in dogs undergoing cholecystectomy because of GBM. Accuracy of using preoperative CRP concentration for detection of GBR was not superior to the accuracy of preoperative abdominal ultrasonography. However, when CRP concentration was combined with results of ultrasonography, the sensitivity, specificity, and accuracy for detection of GBR were 100%, 93%, and 96%, respectively.
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Affiliation(s)
- Makoto Asakawa
- 1Veterinary Specialists Emergency Center, Saitama Prefecture, Japan
| | - Mayuko Fukuzawa
- 1Veterinary Specialists Emergency Center, Saitama Prefecture, Japan
| | | | - James A Flanders
- 2Department of Clinical Sciences, College of Veterinary Medicine, Cornell University, Ithaca, NY
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Akgül F, Er A, Ulusoy E, Çağlar A, Çitlenbik H, Keskinoğlu P, Şişman AR, Karakuş OZ, Özer E, Duman M, Yılmaz D. Integration of Physical Examination, Old and New Biomarkers, and Ultrasonography by Using Neural Networks for Pediatric Appendicitis. Pediatr Emerg Care 2021; 37:e1075-e1081. [PMID: 31503129 DOI: 10.1097/pec.0000000000001904] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The objective of this study was to evaluate physical examinations, imaging, and laboratory analyses individually and combined using innovative statistical analysis methods for the accurate diagnosis of pediatric appendicitis. METHODS Patients admitted to hospital with symptoms of abdominal pain whose pediatric appendicitis scores greater than 3 were included in the study. Clinical, radiologic, and laboratory findings and as a new biomarker calprotectin (CPT) concentrations were evaluated individually and combined using artificial neural networks (ANNs), which revealed latent relationships for a definitive diagnosis. RESULTS Three hundred twenty patients were evaluated (190 appendicitis [43 perforated] vs 130 no appendicitis). The mean ± SD age was 11.3 ± 3.6 years and 63% were male. Pediatric appendicitis scores, white blood cell (WBC) count, absolute neutrophil count (ANC), C-reactive protein (CRP) level, procalcitonin (PCT) and CPT concentrations were higher in the appendicitis group; however, only WBC and ANC were higher in first 24 hours of pain. White blood cells and CRP were diagnostic markers in patients whose appendix could not be visualized using ultrasonography (US). On classic receiver operating characteristic (ROC) analysis, the areas under the curve (AUCs) were not strong enough for differential diagnosis (WBC, 0.73; ANC, 0.72; CRP, 0.65; PCT and CPT, 0.61). However, when the physical examination, US, and laboratory findings were analyzed in a multivariate model and the ROC analysis obtained from the variables with ANN, an ROC curve could be obtained with 0.91 AUC, 89.8% sensitivity, and 81.2% specificity. C-reactive protein and PCT were diagnostic for perforated appendicitis with 0.83 and 0.75 AUC on ROC. CONCLUSIONS Although none of the biomarkers were sufficient for an accurate diagnosis of appendicitis individually, a combination of physical examination and laboratory and US was a good diagnostic tool for pediatric appendicitis.
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Affiliation(s)
- Fatma Akgül
- From the Department of Pediatric Emergency Care
| | - Anıl Er
- From the Department of Pediatric Emergency Care
| | - Emel Ulusoy
- From the Department of Pediatric Emergency Care
| | | | | | | | | | | | - Erdener Özer
- Department of Pathology, Faculty of Medicine, Dokuz Eylul University, Izmir, Turkey
| | - Murat Duman
- From the Department of Pediatric Emergency Care
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Talabi AO, Adedeji TA, Sowande OA, Adejuyigbe O. Predictive values of Alvarado score, serum C-reactive protein, and white blood cell count in the diagnosis of acute appendicitis: a prospective study. ANNALS OF PEDIATRIC SURGERY 2021. [DOI: 10.1186/s43159-021-00074-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
The diagnosis of acute appendicitis in children is quite challenging as the rate of negative appendectomy varies between 15 and 57%. Increased utilization of imaging diagnostic facilities in advanced countries seems to have reduced the incidence of operating on normal appendix to a single digit. In low- and middle-income countries, the incidence remains unacceptably high (double digits). Inflammatory markers and scoring systems may be a suitable adjunct to increase diagnostic yield in most third world countries. Thus, the aim of this study was to evaluate the diagnostic value of Alvarado score, white blood cell count, and serum C-reactive protein in children with acute appendicitis.
Results
The ages of patients ranged between 4 and 15 years with a mean of 11.2 ± 2.8 years. The male to female ratio was 1.4 to 1.0. Nineteen percent of patients had negative appendiceal findings on histological examination. The sensitivity and specificity of Alvarado score, C-reactive protein estimation, total white blood cell count in diagnosing acute appendicitis were 86.4% and 63.2%, 98.8% and 36.8%, and 51.9% and 89.5% respectively. Alvarado score has the highest area under ROC curve analysis 0.824, 95% CI of 0.724 to 0.924 compared with CRP, 0.769. 95% CI of = 0.647 to 0.891 and WBC count, 0.765, 95% CI of 0.643 to 0.887. Both CRP and WBC count showed higher discriminatory values between complicated and uncomplicated appendicitis, p < 0.001.
Conclusion
Alvarado score outperformed other tests in setting the diagnosis of acute appendicitis. However, none of the tests can be relied on wholly for operative decision. Clinical judgement remains the bedrock for diagnosis and operative management.
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The predictors of perforated appendicitis in the pediatric emergency department: A retrospective observational cohort study. Am J Emerg Med 2021; 49:249-252. [PMID: 34167047 DOI: 10.1016/j.ajem.2021.06.028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 06/11/2021] [Accepted: 06/15/2021] [Indexed: 01/07/2023] Open
Abstract
OBJECTIVE Appendiceal perforation has significant effects on perioperative morbidity and postoperative outcome. The present study aimed to identify possible predictive factors associated with perforated appendicitis (PA) in children at admission in the emergency department (ED). METHODS In this retrospective observational cohort study, consecutive medical records of children <18 years old with surgically and histopathologically confirmed acute appendicitis (AA) over three years (2013-2015) were analyzed. Patients were divided into two groups: PA and non-perforated appendicitis (NPA). The differences between the two groups and potential predictors of PA were explored using univariate and multivariate analyses. RESULTS During the study period, 295 patients underwent an appendectomy and had confirmatory AA diagnoses. Ninety-two patients had a PA (31.2%). In the univariate analysis, male gender, vomiting, diarrhea, fever, elevated white blood cell count (WBC) levels, and high C-reactive protein (CRP) were identified as predictors of PA. In the multivariate analysis, male gender (odds ratio [OR]: 3.133; 95% confidence interval [CI]: 1.610-6.096); vomiting (OR: 2.346; 95% CI: 1.141-4.822); diarrhea (OR: 4.549; 95% CI: 1.850-11.181); fever (OR: 3.429; 95% CI: 1.765-6.663); elevated WBC (OR: 2.962; 95% CI: 1.491-5.884) and elevated CRP (OR: 3.061; 95% CI: 1.267-7.396) were variables that predicted the PA in children. CONCLUSION Our data indicate that several clinical and biochemical parameters can reliably distinguish between pediatric PA and NPA at admission in the emergency department.
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10
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García-Amador C, Arteaga Peralta V, de la Plaza Llamas R, Torralba M, Medina Velasco A, Ramia JM. Evaluation of Preoperative Clinical and Serological Determinations in Complicated Acute Appendicitis: A Score for Predicting Complicated Appendicitis. Cir Esp 2021; 99:282-288. [PMID: 32624171 DOI: 10.1016/j.ciresp.2020.05.031] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Revised: 05/27/2020] [Accepted: 05/30/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND To analyze whether clinical and analytical parameters differ according to histopathology in cases of acute appendicitis (AA). METHODS This is a retrospective, observational study including patients (>14 years of age) admitted for suspicion of AA from 1 April 2014 to 31 July 2016. Histopathology was divided into complicated (including perforated and gangrenous AA) and uncomplicated appendicitis (phlegmonous). Sex, age, temperature of patients on admission to the Emergency Department, symptom duration, preoperative white blood cell (WBC) count, neutrophil percentage, mean platelet volume (MPV), platelet distribution width (PDW), C-reactive protein (CRP) and hospital stay were compared in the two groups. RESULTS Three hundred and thirty-five patients were analyzed, and 284 were included. Appendicitis was uncomplicated in 194 (68.3%) and complicated in 90 (31.7%). Age, symptom duration, neutrophil percentage, CRP and hospital stay were higher in the complicated AA group (P < .05). The mean differences between uncomplicated and complicated AA were: age 13.2 years (95% CI: 8.2-18.2), symptom duration 14.1hours (95% CI: 6.3-21.9), neutrophil percentage 5.0% (95% CI: 3.2-6.8), CRP 73.6mg/l (95% CI: 50.0-97.2) and hospital stay 2.2 days (95% CI: 1.4-3.0), with p<0.05 for all these variables. A model based on the preoperative parameters (age, symptom duration, neutrophil percentage and CRP) was calculated to predict the likelihood of complicated AA. The receiver operating characteristic (ROC) of the model had an area under the curve of 0.80 (95% CI 0.75-0.85). CONCLUSION This model is able to diagnose complicated AA without the need for imaging techniques, although it must be validated with prospective analysis.
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Affiliation(s)
- Cristina García-Amador
- Servicio de Cirugía General, Hospital Universitario de Guadalajara, Guadalajara, España.
| | | | | | - Miguel Torralba
- Servicio de Medicina Interna, Hospital Universitario de Guadalajara, Guadalajara, España
| | - Anibal Medina Velasco
- Servicio de Cirugía General, Hospital Universitario de Guadalajara, Guadalajara, España
| | - José Manuel Ramia
- Servicio de Cirugía General, Hospital Universitario de Guadalajara, Guadalajara, España
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11
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Huang WY, Chen CY, Chang YJ, Lee EP, Wu HP. Serum Soluble CD40 Ligand in Predicting Simple Appendicitis and Complicated Appendicitis at Different Time Points in Children. Front Pediatr 2021; 9:676370. [PMID: 34178892 PMCID: PMC8219915 DOI: 10.3389/fped.2021.676370] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2021] [Accepted: 05/12/2021] [Indexed: 12/29/2022] Open
Abstract
Objectives: Appendicitis is a common abdominal emergency in children. It is difficult for clinicians to distinguish between simple appendicitis (SA), gangrenous appendicitis (GA), and ruptured appendicitis (RA) in children based on physical and current laboratory tests. Abdominal computed tomography with the disadvantage of excess radiation exposure is usually used in the emergency room for appendicitis surveys. Serum soluble CD40 ligand (sCD40L) is an inflammatory biomarker. This study aimed to use sCD40L to distinguish SA, GA, and RA. Methods: All patients aged <18 years old with suspected appendicitis were tested once for serum sCD40L within 72 h of appendicitis symptoms. We compared sCD40L levels of SA, GA, and RA individually on days 1, 2, and 3 in patients with normal appendix (NA), a total of nine subgroups. Thereafter, the diagnostic performance of sCD40L in predicting appendicitis and the receiver operating characteristic curves were carried out. Results: Of 116 patients, 42 patients had SA, 20 GA, 44 RA, and 10 NA. We found six subgroups with significant p-values of sCD40L predicting appendicitis as follows: SA on day 2, GA on days 2 and 3, and RA on days 1-3. The sensitivity and specificity of sCD40L at the best cutoff point with 178 pg/mL in these six subgroups range from 0.75 to 1.00 and 0.90, respectively. Conclusions: SCD40L is a good predictor of pediatric appendicitis. Clinicians can use sCD40L to distinguish from SA, GA, and RA in children with suspected appendicitis.
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Affiliation(s)
- Wun-Yan Huang
- Department of Pediatric Emergency Medicine, Children Hospital, China Medical University, Taichung, Taiwan.,Department of Medicine, School of Medicine, China Medical University, Taichung, Taiwan
| | - Chun-Yu Chen
- Department of Pediatric Emergency Medicine, Children Hospital, China Medical University, Taichung, Taiwan.,Department of Medicine, School of Medicine, China Medical University, Taichung, Taiwan
| | - Yu-Jun Chang
- Laboratory of Epidemiology and Biostastics, Changhua Christian Hospital, Changhua, Taiwan
| | - En-Pei Lee
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Linko Chang Gung Memorial Hospital, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Han-Ping Wu
- Department of Pediatric Emergency Medicine, Children Hospital, China Medical University, Taichung, Taiwan.,Department of Medicine, School of Medicine, China Medical University, Taichung, Taiwan.,Department of Medical Research, Children's Hospital, China Medical University, Taichung, Taiwan
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12
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Marcinkevics R, Reis Wolfertstetter P, Wellmann S, Knorr C, Vogt JE. Using Machine Learning to Predict the Diagnosis, Management and Severity of Pediatric Appendicitis. Front Pediatr 2021; 9:662183. [PMID: 33996697 PMCID: PMC8116489 DOI: 10.3389/fped.2021.662183] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Accepted: 04/01/2021] [Indexed: 01/07/2023] Open
Abstract
Background: Given the absence of consolidated and standardized international guidelines for managing pediatric appendicitis and the few strictly data-driven studies in this specific, we investigated the use of machine learning (ML) classifiers for predicting the diagnosis, management and severity of appendicitis in children. Materials and Methods: Predictive models were developed and validated on a dataset acquired from 430 children and adolescents aged 0-18 years, based on a range of information encompassing history, clinical examination, laboratory parameters, and abdominal ultrasonography. Logistic regression, random forests, and gradient boosting machines were used for predicting the three target variables. Results: A random forest classifier achieved areas under the precision-recall curve of 0.94, 0.92, and 0.70, respectively, for the diagnosis, management, and severity of appendicitis. We identified smaller subsets of 6, 17, and 18 predictors for each of targets that sufficed to achieve the same performance as the model based on the full set of 38 variables. We used these findings to develop the user-friendly online Appendicitis Prediction Tool for children with suspected appendicitis. Discussion: This pilot study considered the most extensive set of predictor and target variables to date and is the first to simultaneously predict all three targets in children: diagnosis, management, and severity. Moreover, this study presents the first ML model for appendicitis that was deployed as an open access easy-to-use online tool. Conclusion: ML algorithms help to overcome the diagnostic and management challenges posed by appendicitis in children and pave the way toward a more personalized approach to medical decision-making. Further validation studies are needed to develop a finished clinical decision support system.
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Affiliation(s)
| | - Patricia Reis Wolfertstetter
- Department of Pediatric Surgery and Pediatric Orthopedics, Hospital St. Hedwig of the Order of St. John of God, University Children's Hospital Regensburg (KUNO), Regensburg, Germany
| | - Sven Wellmann
- Division of Neonatology, Hospital St. Hedwig of the Order of St. John of God, University Children's Hospital Regensburg (KUNO), University of Regensburg, Regensburg, Germany
| | - Christian Knorr
- Department of Pediatric Surgery and Pediatric Orthopedics, Hospital St. Hedwig of the Order of St. John of God, University Children's Hospital Regensburg (KUNO), Regensburg, Germany
| | - Julia E Vogt
- Department of Computer Science, ETH Zurich, Zurich, Switzerland
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13
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Clinical Difference between Acute Appendicitis and Acute Right-Sided Colonic Diverticulitis. Emerg Med Int 2020; 2020:4947192. [PMID: 32953179 PMCID: PMC7481953 DOI: 10.1155/2020/4947192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 07/29/2020] [Accepted: 08/06/2020] [Indexed: 11/29/2022] Open
Abstract
Background Clinical presentations of acute appendicitis (AA) and acute right-sided colonic diverticulitis (ARCD) are similar. However, the usual treatment for each disease differs between surgical and conservative management. The aim of this study was to identify clinical differences between AA and ARCD. Method We performed a single-center retrospective study on adult patients, with uncomplicated AA and ARCD confirmed by computed tomography, who visited an emergency department between March 2018 and August 2019. Clinical variables including past medical history, presented symptoms and signs, and laboratory findings were compared between the two groups. A logistic regression analysis was subsequently performed to differentiate ARCD from AA based on results of univariate analyses. Results A total of 212 (79.1%) and 56 (20.9%) patients were enrolled in AA and ARSD groups, respectively. Logistic regression analysis revealed that a past history of diverticulitis [OR: 102.679 (95% CI: 9.964–1058.055), p < 0.001] was associated with ARCD, while ketonuria [OR: 2.907 (95% CI: 1.091–7.745), p=0.033], anorexia [OR: 21.544 (95% CI: 3.905–118.868), p < 0.001], and neutrophilia [OR: 3.406 (95% CI: 1.243–9.336), p=0.017] were associated with AA. Conclusion Anorexia, neutrophilia, and ketonuria were predictors of AA while a history of diverticulitis was a predictor of ARCD.
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14
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Stankovic N, Surbatovic M, Stanojevic I, Simić R, Djuricic S, Milickovic M, Grujic B, Savic D, Marinovic VM, Stankovic M, Vojvodic D. Possible cytokine biomarkers in pediatric acute appendicitis. Ital J Pediatr 2019; 45:125. [PMID: 31615548 PMCID: PMC6794741 DOI: 10.1186/s13052-019-0726-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Accepted: 09/30/2019] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Diagnosis of acute appendicitis (AA) and decisions about its treatment remain among the most common dilemmas of pediatric surgical teams. Monitoring of immune response may be of importance for this purpose. Our aim was to measure and analyze serum and peritoneal fluid cytokines, in children who had undergone surgery for suspected AA. METHODS Prospective investigation of serum and peritoneal fluid cytokine values was performed in 127 consecutive patients. According to the pathohistological findings, patients were divided into three groups: normal/early, uncomplicated and complicated AA. Determination of cytokine concentrations for 20 different cytokines was done using a commercial flow cytometry kit: Human Inflammation 20 plex BMS 819. RESULTS Statistically significant differences in serum cytokine values between pathohistological groups were found for IP-10, MIP-1α and IL-10. Preoperative cut-off values of IP-10, MIP-1α and IL-10 between groups were obtained using ROC curve analysis. Positive correlations between serum and peritoneal concentrations were recorded for most of the analyzed cytokines. CONCLUSION IP-10, MIP-1α and IL-10 showed potential in assessment of AA in children. Confirmatory studies with a larger number of patients are required to prove reliability of these biomarkers.
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Affiliation(s)
- Nikola Stankovic
- Mother And Child Health Care Institute of Serbia, Radoja Dakica 6, Belgrade, 11000, Serbia. .,Faculty of Medicine, University of Belgrade, Belgrade, Serbia.
| | - Maja Surbatovic
- Military Medical Academy, Belgrade, Serbia.,Faculty of Medicine of the Military Medical Academy, University of Defence, Belgrade, Serbia
| | - Ivan Stanojevic
- Military Medical Academy, Belgrade, Serbia.,Faculty of Medicine of the Military Medical Academy, University of Defence, Belgrade, Serbia
| | - Radoje Simić
- Mother And Child Health Care Institute of Serbia, Radoja Dakica 6, Belgrade, 11000, Serbia.,Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Slavisa Djuricic
- Mother And Child Health Care Institute of Serbia, Radoja Dakica 6, Belgrade, 11000, Serbia.,Banjaluka University School of Medicine, Banjaluka, Bosnia and Herzegovina
| | - Maja Milickovic
- Mother And Child Health Care Institute of Serbia, Radoja Dakica 6, Belgrade, 11000, Serbia.,Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Blagoje Grujic
- Mother And Child Health Care Institute of Serbia, Radoja Dakica 6, Belgrade, 11000, Serbia.,Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Djordje Savic
- Mother And Child Health Care Institute of Serbia, Radoja Dakica 6, Belgrade, 11000, Serbia.,Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Vesna Milojkovic Marinovic
- Mother And Child Health Care Institute of Serbia, Radoja Dakica 6, Belgrade, 11000, Serbia.,Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | | | - Danilo Vojvodic
- Military Medical Academy, Belgrade, Serbia.,Faculty of Medicine of the Military Medical Academy, University of Defence, Belgrade, Serbia
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15
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Sasaki Y, Komatsu F, Kashima N, Sato T, Takemoto I, Kijima S, Maeda T, Ishii T, Miyazaki T, Honda Y, Shimada N, Urita Y. Clinical differentiation of acute appendicitis and right colonic diverticulitis: A case-control study. World J Clin Cases 2019; 7:1393-1402. [PMID: 31363467 PMCID: PMC6656680 DOI: 10.12998/wjcc.v7.i12.1393] [Citation(s) in RCA: 2] [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: 03/11/2019] [Revised: 04/13/2019] [Accepted: 05/11/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Acute right colonic diverticulitis (ARCD) is an important differential diagnosis of acute appendicitis (AA) in Asian countries because of the unusually high prevalence of right colonic diverticula. Due to qualitative improvement and the high penetration rate of computed tomography (CT) scanning in Japan, differentiation of ARCD and AA mainly depends on this modality. But cost, limited availability, and concern for radiation exposure make CT scanning problematic. Differential findings of ARCD from AA are based on several small studies that used univariate comparisons from Korea and Taiwan. Previous studies on clinical and laboratory differences between AA and ARCD are limited.
AIM To determine clinical differences between AA and ARCD for differentiation of these two diagnoses by creating a logistic regression model.
METHODS We performed an exploratory single-center retrospective case-control study evaluating 369 Japanese patients (age ≥ 16 years), 236 (64.0%) with AA and 133 (36.0%) with ARCD, who were hospitalized between 2012 and 2016. Diagnoses were confirmed by CT images. We compared age, sex, onset-to-visit interval, epigastric/periumbilical pain, right lower quadrant (RLQ) pain, nausea/vomiting, diarrhea, anorexia, medical history, body temperature, blood pressure, heart rate, RLQ tenderness, peritoneal signs, leukocyte count, and levels of serum creatinine, serum C-reactive protein (CRP), and serum alanine aminotrans-ferase. We subsequently performed logistic regression analysis for differentiating AA from ARCD based on the results of the univariate analyses.
RESULTS In the AA and ARCD groups, median ages were 35.5 and 41.0 years, respectively (p=0.011); median onset-to-visit intervals were 1 [interquartile range (IQR): 0-1] and 2 (IQR: 1-3) days, respectively (P < 0.001); median leukocyte counts were 12600 and 11500/mm3, respectively (P = 0.002); and median CRP levels were 1.1 (IQR: 0.2-4.1) and 4.9 (IQR: 2.9-8.5) mg/dL, respectively (P < 0.001). In the logistic regression model, odds ratios (ORs) were significantly high in nausea/vomiting (OR: 3.89, 95%CI: 2.04-7.42) and anorexia (OR: 2.13, 95%CI: 1.06-4.28). ORs were significantly lower with a longer onset-to-visit interval (OR: 0.84, 95%CI: 0.72-0.97), RLQ pain (OR: 0.28, 95%CI: 0.11-0.71), history of diverticulitis (OR: 0.034, 95%CI: 0.005-0.20), and CRP level > 3.0 mg/dL (OR: 0.25, 95%CI: 0.14-0.43). The regression model showed good calibration, discrimination, and optimism.
CONCLUSION Clinical findings can differentiate AA and ARCD before imaging studies; nausea/vomiting and anorexia suggest AA, and longer onset-to-visit interval, RLQ pain, previous diverticulitis, and CRP level > 3.0 mg/dL suggest ARCD.
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Affiliation(s)
- Yosuke Sasaki
- Department of General Medicine and Emergency Care, Toho University School of Medicine, Ota-ku, Tokyo 143-8541, Japan
| | - Fumiya Komatsu
- Department of General Medicine and Emergency Care, Toho University School of Medicine, Ota-ku, Tokyo 143-8541, Japan
| | - Naoyasu Kashima
- Department of General Medicine and Emergency Care, Toho University School of Medicine, Ota-ku, Tokyo 143-8541, Japan
| | - Takahiro Sato
- Department of General Medicine and Emergency Care, Toho University School of Medicine, Ota-ku, Tokyo 143-8541, Japan
| | - Ikutaka Takemoto
- Department of General Medicine and Emergency Care, Toho University School of Medicine, Ota-ku, Tokyo 143-8541, Japan
| | - Sho Kijima
- Department of General Medicine and Emergency Care, Toho University School of Medicine, Ota-ku, Tokyo 143-8541, Japan
| | - Tadashi Maeda
- Department of General Medicine and Emergency Care, Toho University School of Medicine, Ota-ku, Tokyo 143-8541, Japan
| | - Takamasa Ishii
- Department of General Medicine and Emergency Care, Toho University School of Medicine, Ota-ku, Tokyo 143-8541, Japan
| | - Taito Miyazaki
- Department of General Medicine and Emergency Care, Toho University School of Medicine, Ota-ku, Tokyo 143-8541, Japan
| | - Yoshiko Honda
- Department of General Medicine and Emergency Care, Toho University School of Medicine, Ota-ku, Tokyo 143-8541, Japan
| | - Nagato Shimada
- Department of General Medicine and Emergency Care, Toho University School of Medicine, Ota-ku, Tokyo 143-8541, Japan
| | - Yoshihisa Urita
- Department of General Medicine and Emergency Care, Toho University School of Medicine, Ota-ku, Tokyo 143-8541, Japan
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16
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March B, Leigh L, Brussius-Coelho M, Holmes M, Pockney P, Gani J. Can CRP velocity in right iliac fossa pain identify patients for intervention? A prospective observational cohort study. Surgeon 2018; 17:284-290. [PMID: 30309747 DOI: 10.1016/j.surge.2018.08.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2018] [Revised: 08/11/2018] [Accepted: 08/25/2018] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Previous studies have shown single CRP measurements at time of presentation to have limited predictive benefit for appendicitis. Our objective was to determine the diagnostic utility of serial CRP measurements (to determine CRP velocity [CRPv]) in patients with right iliac fossa (RIF) pain. METHODS A single-centre prospective observational study was conducted on adult patients admitted with RIF pain. CRP was measured on admission, at midnight, and the following morning. Appendicitis was diagnosed on histopathology, or diagnostic imaging in non-operatively managed patients. Therapeutic interventions included all appropriate operative procedures and effective non-operative treatment with antibiotics. Logistic regression was used to generate predictors of therapeutic intervention, and then used to create a new risk score incorporating CRPv. RESULTS 98 of 112 (87.5%) participants had complete CRP data. 58 patients met the criteria for appendicitis (59.2%). Most patients presented with intermediate Modified Alvarado Scores (MAS) 5-6 (40.8%) or Appendicitis Inflammatory Response Scores (AIRS) 5-8 (49%). Our risk score had an AUROC of 0.88 (95% CI 0.81-0.96) in predicting therapeutic intervention. This score was superior to MAS, AIRS, and single admission biomarker measurements. Patients with an increasing CRPv had 14 times the odds (OR 14.07, 95% CI 0.63-315.2) of complicated appendicitis, and no cases of complicated appendicitis were observed in patients with a flat CRPv. CONCLUSIONS CRP velocity is superior to single CRP at predicting intervention. Our v-Score shows promise as a decision making-aide by predicting the need for surgical intervention in RIF pain. A flat CRPv identifies a group of patients with a very low risk of complicated appendicitis.
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Affiliation(s)
- Brayden March
- Department of Surgery, John Hunter Hospital, Newcastle, NSW, Australia; University of Newcastle, NSW, Australia
| | - Lucy Leigh
- Hunter Medical Research Institute, Newcastle, NSW, Australia
| | | | - Merran Holmes
- Department of Surgery, John Hunter Hospital, Newcastle, NSW, Australia; University of Newcastle, NSW, Australia
| | - Peter Pockney
- Department of Surgery, John Hunter Hospital, Newcastle, NSW, Australia; University of Newcastle, NSW, Australia
| | - Jon Gani
- Department of Surgery, John Hunter Hospital, Newcastle, NSW, Australia; University of Newcastle, NSW, Australia.
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17
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Msolli MA, Beltaief K, Bouida W, Jerbi N, Grissa MH, Boubaker H, Boukef R, Nouira S. Value of early change of serum C reactive protein combined to modified Alvarado score in the diagnosis of acute appendicitis. BMC Emerg Med 2018; 18:15. [PMID: 29793425 PMCID: PMC5968536 DOI: 10.1186/s12873-018-0166-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2017] [Accepted: 05/15/2018] [Indexed: 11/12/2022] Open
Abstract
Background The aim of this study is to test the diagnostic value of baseline and early change of C-reactive protein (CRP) concentrations, evaluated separately or in combination with the modified Alvarado score (MAS), in patients with clinically suspected acute appendicitis. Methods This is a prospective observational study including all patients presenting to the emergency department with an equivocal diagnosis of acute appendicitis. After inclusion, clinical and demographic data are recorded and blood samples were taken at baseline and 3 h after for serum CRP measurements (3 h CRP). The MAS is also calculated for all patients. The ultimate diagnosis of appendicitis was based on the histologic findings of the excised appendix in operated patients and clinical follow-up in emergency department discharged patients. Diagnostic accuracy of admission CRP, early change of CRP 3 h CRP minus admission CRP, MAS and the combination of these parameters was expressed by sensitivity, specificity, positive predictive value, negative predictive value and area under receiver operating characteristics curve. Results Five hundred patients were included from January 2010 to December 2013. Overall, 387 patients were operated the negative appendectomy rate was 8,3%. CRP concentrations were higher in patients with acute appendicitis. However, the diagnostic value of admission CRP, delta CRP and MAS was moderate with area under ROC curve respectively equal to 0.63, 0.53 and 0.6. Combining admission CRP and delta CRP values to MAS did not result in a better performance. The area under ROC curve did not exceed 0.7 with the different combinations. Conclusion Early change of CRP has a moderate diagnostic value in patients with clinically suspected acute appendicitis. Combining CRP values to MAS did not improve diagnostic accuracy.
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Affiliation(s)
- Mohamed Amine Msolli
- Emergency Department, FattoumaBourguiba University Hospital Monastir, 5000, Monastir, Tunisia. .,Research Laboratory (LR12SP18), University of Monastir, 5000, Monastir, Tunisia.
| | - Kaouther Beltaief
- Emergency Department, FattoumaBourguiba University Hospital Monastir, 5000, Monastir, Tunisia.,Research Laboratory (LR12SP18), University of Monastir, 5000, Monastir, Tunisia
| | - Wahid Bouida
- Emergency Department, FattoumaBourguiba University Hospital Monastir, 5000, Monastir, Tunisia.,Research Laboratory (LR12SP18), University of Monastir, 5000, Monastir, Tunisia
| | - Nahla Jerbi
- Emergency Department, Mahdia University Hospital, 5100, Mahdia, Tunisia.,Research Laboratory (LR12SP18), University of Monastir, 5000, Monastir, Tunisia
| | - Mohamed Habib Grissa
- Emergency Department, FattoumaBourguiba University Hospital Monastir, 5000, Monastir, Tunisia.,Research Laboratory (LR12SP18), University of Monastir, 5000, Monastir, Tunisia
| | - Hamdi Boubaker
- Emergency Department, FattoumaBourguiba University Hospital Monastir, 5000, Monastir, Tunisia.,Research Laboratory (LR12SP18), University of Monastir, 5000, Monastir, Tunisia
| | - Riadh Boukef
- Emergency Department, Sahloul University Hospital, 4011, Sousse, Tunisia.,Research Laboratory (LR12SP18), University of Monastir, 5000, Monastir, Tunisia
| | - Semir Nouira
- Emergency Department, FattoumaBourguiba University Hospital Monastir, 5000, Monastir, Tunisia.,Research Laboratory (LR12SP18), University of Monastir, 5000, Monastir, Tunisia
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18
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Prada Arias M, Salgado Barreira A, Montero Sánchez M, Fernández Eire P, García Saavedra S, Gómez Veiras J, Fernández Lorenzo JR. Appendicitis versus non-specific acute abdominal pain: Paediatric Appendicitis Score evaluation. ANALES DE PEDIATRÍA (ENGLISH EDITION) 2018. [DOI: 10.1016/j.anpede.2017.01.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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19
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Shin DH, Cho YS, Cho GC, Ahn HC, Park SM, Lim SW, Oh YT, Cho JW, Park SO, Lee YH. Delta neutrophil index as an early predictor of acute appendicitis and acute complicated appendicitis in adults. World J Emerg Surg 2017; 12:32. [PMID: 28747992 PMCID: PMC5525197 DOI: 10.1186/s13017-017-0140-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2017] [Accepted: 06/16/2017] [Indexed: 12/20/2022] Open
Abstract
Background This retrospective study aimed to evaluate the ability of the delta neutrophil index (DNI) to predict histologically normal appendicitis preoperatively and to differentiate between simple and complicated appendicitis. Methods The data from 650 patients were divided into positive and negative appendectomy groups (histologically normal appendicitis). The patients in the acute appendicitis group were further sub-divided into simple and complicated appendicitis groups. Results The DNI was significantly higher in the positive group than in the negative appendectomy group (0.4 vs. −0.4, p < 0.001) as well as in the complicated group compared with that in the simple appendicitis group (1.2 vs. 0.3, p < 0.001). The DNI independently predicted a positive appendectomy and an acute complicated appendicitis in multivariate logistic regression analysis [odds ratio (OR) 2.62, 95% confidence interval (CI) (1.11~6.16), p = 0.028 and odds ratio (OR) 4.10, 95% confidence interval (CI) (2.94~5.80), p < 0.001]. The optimum cut-off for a positive appendectomy and acute complicated appendicitis were 0.2 [area under curve (AUC) 0.709] and 0.6 (AUC 0.727). Conclusions We suggest that obtaining a preoperative DNI is a useful parameter to aid in the diagnosis of histologically normal appendicitis and to differentiate between simple and complicated appendicitis.
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Affiliation(s)
- Dong Hyuk Shin
- Department of Emergency Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Young Suk Cho
- Department of Emergency Medicine, School of Medicine, Kangdong Sacred Heart Hospital, Hallym University, Seoul, Republic of Korea
| | - Gyu Chong Cho
- Department of Emergency Medicine, School of Medicine, Kangdong Sacred Heart Hospital, Hallym University, Seoul, Republic of Korea
| | - Hee Cheol Ahn
- Department of Emergency Medicine, Sacred Heart Hospital, Hallym University School of Medicine, Anyang, Republic of Korea
| | - Seung Min Park
- Department of Emergency Medicine, Sacred Heart Hospital, Hallym University School of Medicine, Anyang, Republic of Korea
| | - Seung Wook Lim
- Department of Emergency Medicine, Sacred Heart Hospital, Hallym University School of Medicine, Anyang, Republic of Korea
| | - Young Taeck Oh
- Department of Emergency Medicine, Sacred Heart Hospital, Hallym University School of Medicine, Anyang, Republic of Korea.,Department of Emergency Medicine, College of Medicine, Kangwon National University, Chuncheon, Gangwon 200-701 Republic of Korea
| | - Ji Woong Cho
- Department of Surgery, Kangnam Sacred Heart Hospital, Hallym University Medical Center, Hallym University College of Medicine, Seoul, Republic of Korea
| | - Sang O Park
- Department of Emergency Medicine, School of Medicine, Konkuk University Konkuk University Medical Center, Seoul, Republic of Korea
| | - Young Hwan Lee
- Department of Emergency Medicine, Sacred Heart Hospital, Hallym University School of Medicine, Anyang, Republic of Korea.,Department of Emergency Medicine, College of Medicine, Kangwon National University, Chuncheon, Gangwon 200-701 Republic of Korea
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20
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Kabir SA, Kabir SI, Sun R, Jafferbhoy S, Karim A. How to diagnose an acutely inflamed appendix; a systematic review of the latest evidence. Int J Surg 2017; 40:155-162. [PMID: 28279749 DOI: 10.1016/j.ijsu.2017.03.013] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2016] [Revised: 02/11/2017] [Accepted: 03/04/2017] [Indexed: 02/08/2023]
Abstract
Acute appendicitis is the most common condition that presents with an acute abdomen needing emergency surgery. Despite this common presentation, correctly diagnosing appendicitis remains a challenge as clinical signs or positive blood results can be absent in 55% of the patients. The reported proportion of missed diagnoses of appendicitis ranges between 20% and 40%. A delay or mis-diagnosis of appendicitis can result in severe complications such as perforation, abscess formation, sepsis, and intra-abdominal adhesions. Literature has shown that patients who had a negative appendectomy suffer post-op complications and infections secondary to hospital stays; there have even been reported cases of fatality. It is therefore crucial that timely and accurate diagnosis of appendicitis is achieved to avoid complications of both non-operating as well as unnecessary surgical intervention. The aim of this review is to systematically report and analyse the latest evidence on the different approaches used in diagnosing appendicitis. We include discussions of clinical scoring systems, laboratory tests, latest innovative bio-markers and radiological imaging.
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Affiliation(s)
- S A Kabir
- Department of Surgery, Worcester Royal Hospital, UK.
| | - S I Kabir
- Department of Surgery, Oxford University Hospitals NHS Trust, UK
| | - R Sun
- Department of Surgery, Worcester Royal Hospital, UK
| | | | - Ahmed Karim
- Department of Surgery, Worcester Royal Hospital, UK
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21
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Prada Arias M, Salgado Barreira A, Montero Sánchez M, Fernández Eire P, García Saavedra S, Gómez Veiras J, Fernández Lorenzo JR. [Appendicitis versus non-specific acute abdominal pain: Paediatric Appendicitis Score evaluation]. An Pediatr (Barc) 2017; 88:32-38. [PMID: 28254168 DOI: 10.1016/j.anpedi.2017.01.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2016] [Revised: 01/15/2017] [Accepted: 01/17/2017] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION Non-specific acute abdominal pain is the most common process requiring differential diagnosis with appendicitis in clinical practice. The aim of this study was to assess the Paediatric Appendicitis Score in differentiating between these two entities. MATERIAL AND METHODS All patients admitted due to suspicion of appendicitis were prospectively evaluated in our hospital over a two-year period. Cases of non-specific acute abdominal pain and appendicitis were enrolled in the study. Several variables were collected, including Score variables and C-reactive protein levels. Descriptive, univariate and multivariate analyses and diagnostic accuracy studies (ROC curves) were performed. RESULTS A total of 275 patients were studied, in which there were 143 cases of non-specific acute abdominal pain and 132 cases of appendicitis. Temperature and right iliac fossa tenderness on palpation were the variables without statistically significant differences, and with no discrimination power between groups. Pain on coughing, hopping, and/or percussion tenderness in the right lower quadrant was the variable with greater association with appendicitis. The Score correctly stratified the patients into risk groups. Substitution of temperature for C-reactive protein in the Score increased diagnostic accuracy, although with no statistically significant differences. CONCLUSIONS The Paediatric Appendicitis Score helps in differential diagnosis between appendicitis and non-specific acute abdominal pain. It would be advisable to replace the temperature in the Score, since it has no discrimination power between these groups. C-reactive protein at a cut-off value of 25.5mg/L value could be used instead.
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Affiliation(s)
- Marcos Prada Arias
- Sección de Cirugía Pediátrica, Hospital Universitario Álvaro Cunqueiro, Vigo, Pontevedra, España; Instituto de Investigación Sanitaria Galicia Sur, Hospital Universitario Álvaro Cunqueiro, Vigo, Pontevedra, España.
| | - Angel Salgado Barreira
- Unidad de apoyo a la Investigación, Hospital Universitario Álvaro Cunqueiro, Vigo, Pontevedra, España; Instituto de Investigación Sanitaria Galicia Sur, Hospital Universitario Álvaro Cunqueiro, Vigo, Pontevedra, España
| | - Margarita Montero Sánchez
- Sección de Cirugía Pediátrica, Hospital Universitario Álvaro Cunqueiro, Vigo, Pontevedra, España; Instituto de Investigación Sanitaria Galicia Sur, Hospital Universitario Álvaro Cunqueiro, Vigo, Pontevedra, España
| | - Pilar Fernández Eire
- Sección de Cirugía Pediátrica, Hospital Universitario Álvaro Cunqueiro, Vigo, Pontevedra, España; Instituto de Investigación Sanitaria Galicia Sur, Hospital Universitario Álvaro Cunqueiro, Vigo, Pontevedra, España
| | - Silvia García Saavedra
- Sección de Cirugía Pediátrica, Hospital Universitario Álvaro Cunqueiro, Vigo, Pontevedra, España
| | - Javier Gómez Veiras
- Sección de Cirugía Pediátrica, Hospital Universitario Álvaro Cunqueiro, Vigo, Pontevedra, España
| | - José Ramón Fernández Lorenzo
- Servicio de Pediatría, Hospital Universitario Álvaro Cunqueiro, Vigo, Pontevedra, España; Instituto de Investigación Sanitaria Galicia Sur, Hospital Universitario Álvaro Cunqueiro, Vigo, Pontevedra, España
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22
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Boshnak N, Boshnaq M, Elgohary H. Evaluation of Platelet Indices and Red Cell Distribution Width as New Biomarkers for the Diagnosis of Acute Appendicitis. J INVEST SURG 2017. [PMID: 28635513 DOI: 10.1080/08941939.2017.1284964] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Debate around the value of laboratory tests in establishing the diagnosis of acute appendicitis (AA) still continues. This prospective study aimed to investigate the changes in mean platelet volume (MPV), platelet distribution width (PDW), and red cell distribution width (RDW) with the diagnosis of acute appendicitis. METHOD 200 patients who underwent emergency appendectomy were included. According to postoperative histology, patients were divided into three groups: acute non-complicated, acute complicated appendicitis (positive appendicectomy groups), and negative appendectomy group. White blood cell (WBC), neutrophil, lymphocyte count, neutrophil-to-lymphocyte ratio (NLR), platelets (PLT) count, MPV, PDW, RDW, and C-reactive protein (CRP) were compared among the groups. RESULTS One hundred twenty-five (62.5%) patients had non-complicated acute appendicitis, 20 (10%) had complicated acute appendicitis, while 55 (27.5%) had normal appendix. WBC (p <.001), neutrophil (p <.001), NLR (p <.001), PDW (p =.003), and CRP (p =.001) were higher, while lymphocyte (p <.001) and PLT counts (p =.020) were lower in positive appendectomy compared with negative appendectomy patients. MPV levels were insignificantly different across the groups. RDW level was significantly higher in complicated compared with non-complicated acute appendicitis (p =.006); however, no significant difference was found between positive and negative appendectomy groups. Using receiver operating characteristic analysis, sensitivity, specificity, and diagnostic accuracy respectively were 44.83, 100.0, and 72.415% for WBC count, 72.41, 81.82, and 77.115% for neutrophil count, 48.28, 90.91, and 69.595% for PDW, 89.66, 63.64, and 76.65% for CRP. CONCLUSIONS Increased PDW combined with elevated WBC and neutrophil counts maybe used as diagnostic tests in the cases of acute appendicitis, while MPV and RDW levels were not useful diagnostic markers.
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Affiliation(s)
- Noha Boshnak
- a Department of Clinical Pathology, Faculty of Medicine , Ain Shams University , Cairo , Egypt
| | - Mohamed Boshnaq
- b Department of General Surgery , Queen Elizabeth the Queen Mother Hospital , Margate , Kent , UK.,c Department of General Surgery, Faculty of Medicine , Ain Shams University , Cairo , Egypt
| | - Hatem Elgohary
- d Department of General Surgery, Faculty of Medicine , Helwan University , Cairo , Egypt
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Abstract
Abdominal pain is a common complaint that leads to pediatric patients seeking emergency care. The emergency care provider has the arduous task of determining which child likely has a benign cause and not missing the devastating condition that needs emergent attention. This article reviews common benign causes of abdominal pain as well as some of the cannot-miss emergent causes.
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Affiliation(s)
- Jeremiah Smith
- Department of Emergency Medicine, Carolinas Medical Center, 1000 Blythe Boulevard, MEB Floor 3, Charlotte, NC 28203, USA.
| | - Sean M Fox
- Emergency Medicine Residency Program, Department of Emergency Medicine, Carolinas Medical Center, 1000 Blythe Boulevard, MEB Floor 3, Charlotte, NC 28203, USA
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Prada-Arias M, Vázquez JL, Salgado-Barreira Á, Gómez-Veiras J, Montero-Sánchez M, Fernández-Lorenzo JR. Diagnostic accuracy of fibrinogen to differentiate appendicitis from nonspecific abdominal pain in children. Am J Emerg Med 2017; 35:66-70. [PMID: 27760719 DOI: 10.1016/j.ajem.2016.10.003] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2016] [Revised: 09/07/2016] [Accepted: 10/03/2016] [Indexed: 12/29/2022] Open
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Dayawansa NH, Segan JDS, Yao HHI, Chong HI, Sitzler PJ. Incidence of normal white cell count and C-reactive protein in adults with acute appendicitis. ANZ J Surg 2016; 88:E539-E543. [DOI: 10.1111/ans.13760] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2016] [Accepted: 07/26/2016] [Indexed: 12/15/2022]
Affiliation(s)
- Nalin H. Dayawansa
- Department of General Surgery; Sandringham Hospital; Melbourne Victoria Australia
| | - Julian D. S. Segan
- Department of General Surgery; Sandringham Hospital; Melbourne Victoria Australia
| | - Henry H. I. Yao
- Department of General Surgery; Sandringham Hospital; Melbourne Victoria Australia
| | - Hon I. Chong
- Department of General Surgery; Sandringham Hospital; Melbourne Victoria Australia
| | - Paul J. Sitzler
- Department of General Surgery; Sandringham Hospital; Melbourne Victoria Australia
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Biomarkers of acute appendicitis: systematic review and cost-benefit trade-off analysis. Surg Endosc 2016; 31:1022-1031. [PMID: 27495334 PMCID: PMC5315733 DOI: 10.1007/s00464-016-5109-1] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2016] [Accepted: 07/09/2016] [Indexed: 12/12/2022]
Abstract
Background Acute appendicitis is the most common surgical emergency and can represent a challenging diagnosis, with a negative appendectomy rate as high as 20 %. This review aimed to evaluate the clinical utility of individual biomarkers in the diagnosis of appendicitis and appraise the quality of these studies. Methods A systematic review of the literature between January 2000 and September 2015 using of PubMed, OvidMedline, EMBASE and Google Scholar was conducted. Studies in which the diagnostic accuracy, statistical heterogeneity and predictive ability for severity of several biomarkers could be elicited were included. Information regarding costs and process times was retrieved from the regional laboratory. European surgeons blinded to these reviews were independently asked to rank which characteristics of biomarkers were most important in acute appendicitis to inform a cost–benefit trade-off. Sensitivity testing and the QUADAS-2 tool were used to assess the robustness of the analysis and study quality, respectively. Results Sixty-two studies met the inclusion criteria and were assessed. Traditional biomarkers (such as white cell count) were found to have a moderate diagnostic accuracy (0.75) but lower costs in the diagnosis of acute appendicitis. Conversely, novel markers (pro-calcitonin, IL 6 and urinary 5-HIAA) were found to have high process-related costs including analytical times, but improved diagnostic accuracy. QUADAS-2 analysis revealed significant potential biases in the literature. Conclusion When assessing biomarkers, an appreciation of the trade-offs between the costs and benefits of individual biomarkers is needed. Further studies should seek to investigate new biomarkers and address concerns over bias, in order to improve the diagnosis of acute appendicitis. Electronic supplementary material The online version of this article (doi:10.1007/s00464-016-5109-1) contains supplementary material, which is available to authorized users.
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27
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van den Bogaard VAB, Euser SM, van der Ploeg T, de Korte N, Sanders DGM, de Winter D, Vergroesen D, van Groningen K, de Winter P. Diagnosing perforated appendicitis in pediatric patients: a new model. J Pediatr Surg 2016; 51:444-8. [PMID: 26628202 DOI: 10.1016/j.jpedsurg.2015.10.054] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2015] [Revised: 10/21/2015] [Accepted: 10/21/2015] [Indexed: 12/29/2022]
Abstract
OBJECTIVE Studies have investigated sensitivity and specificity of symptoms and tests for diagnosing appendicitis in children. Less is known with regard to the predictive value of these symptoms and tests with respect to the severity of appendicitis. The aim of this study was to determine the predictive value of patient's characteristics and tests for discriminating between perforated and nonperforated appendicitis in children. PATIENTS AND METHODS Pediatric patients who underwent an appendectomy at Spaarne Hospital Hoofddorp, the Netherlands, between January 1, 2009 and December 31, 2013, were included. Baseline patient's characteristics, history, physical examination, laboratory data and results of ultrasounds were collected. Univariate and multivariate logistic regressions were used to determine predictors of perforation. RESULTS In total, 375 patients were included in this study of which 97 children (25.9%) had significant signs of perforation. Univariate analysis showed that age, duration of complaints, temperature, vomiting, CRP, WBC, different findings on ultrasound and the diameter of the appendix were good predictors of a perforated appendicitis. The final multivariate prediction model included temperature, CRP, clearly visible appendix and free fluids on ultrasound and diameter of the appendix and resulted in an area under the curve (AUC) of 0.91 showing sensitivity and specificity of respectively 85.2% and 81.2%. CONCLUSION This prediction model can be used for identification of 'high-risk' children for a perforated appendicitis and might be helpful to prevent complications and longer hospitalization by bringing these children to theater earlier.
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Affiliation(s)
| | - Sjoerd M Euser
- Regional Public Health Laboratory Kennemerland, Haarlem, the Netherlands
| | | | - Niels de Korte
- Department of Surgery, Spaarne Hospital, Hoofddorp, the Netherlands
| | - Dave G M Sanders
- Department of Radiology, Spaarne Hospital, Hoofddorp, the Netherlands
| | - Derek de Winter
- Department of Pediatrics, Spaarne Hospital, Hoofddorp, the Netherlands
| | | | | | - Peter de Winter
- Department of Pediatrics, Spaarne Hospital, Hoofddorp, the Netherlands
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Atema JJ, Gans SL, Beenen LF, Toorenvliet BR, Laurell H, Stoker J, Boermeester MA. Accuracy of White Blood Cell Count and C-reactive Protein Levels Related to Duration of Symptoms in Patients Suspected of Acute Appendicitis. Acad Emerg Med 2015; 22:1015-24. [PMID: 26291309 DOI: 10.1111/acem.12746] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2015] [Revised: 03/31/2015] [Accepted: 04/08/2015] [Indexed: 12/13/2022]
Abstract
OBJECTIVES Low levels of white blood cell (WBC) count and C-reactive protein (CRP) have been suggested to sufficiently rule out acute appendicitis. The diagnostic value of these tests is likely to depend on the duration of complaints. The aim of this study was to evaluate the accuracy of these inflammatory markers in relation to duration of symptoms in patients suspected of acute appendicitis. METHODS Patients suspected of having acute appendicitis were retrospectively selected from five prospective cohorts of patients with acute abdominal pain presenting at the emergency department (ED) in two European countries. Only adult patients with clinical suspicion of acute appendicitis based on medical history, physical examination, and laboratory studies at the time of registration in the original cohorts were included in this analysis. WBC count and CRP level were determined in all patients and a final diagnosis was assigned to every patient by an expert panel based on all available clinical data and follow-up. For categories based on symptom duration, the diagnostic accuracy of single and combined cutoff values was determined, and negative predictive values (NPV) and positive predictive values (PPV) were calculated. Subgroup analyses for age (<40 years or ≥40 years) and sex were performed. RESULTS A total of 1,024 patients with clinically suspected acute appendicitis were included, of whom 580 (57%) were assigned a final diagnosis of appendicitis. No value of WBC count, CRP level, or their combination resulted in a NPV of more than 90%, regardless of the duration of symptoms. A WBC count of >20 × 10(9) /L in combination with symptoms for more than 48 hours was associated with a PPV of 100%. However, only eight of the 1,024 patients (1%) fulfilled these criteria, limiting the clinical applicability. No other cutoff level of WBC count, CRP level, or their combination resulted in a PPV of more than 80%, regardless of the duration of symptoms. In female patients, normal levels of CRP and WBC count more accurately excluded the diagnosis of appendicitis than normal levels did in male patients. CONCLUSIONS No WBC count or CRP level can safely and sufficiently confirm or exclude the suspected diagnosis of acute appendicitis in patients who present with abdominal pain of 5 days or less in duration.
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Affiliation(s)
- Jasper J. Atema
- Department of Surgery; Academic Medical Centre; Amsterdam the Netherlands
| | - Sarah L. Gans
- Department of Surgery; Academic Medical Centre; Amsterdam the Netherlands
| | - Ludo F. Beenen
- Department of Radiology; Academic Medical Centre; Amsterdam the Netherlands
| | | | | | - Jaap Stoker
- Department of Radiology; Academic Medical Centre; Amsterdam the Netherlands
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Adams HL, Jaunoo SS. Hyperbilirubinaemia in appendicitis: the diagnostic value for prediction of appendicitis and appendiceal perforation. Eur J Trauma Emerg Surg 2015; 42:249-52. [PMID: 26038057 DOI: 10.1007/s00068-015-0540-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2015] [Accepted: 05/11/2015] [Indexed: 11/25/2022]
Abstract
AIM The aim of this study is to evaluate the diagnostic value of pre-operative bilirubin levels in the diagnosis of acute appendicitis and appendiceal perforation. METHOD A retrospective analysis of 557 patients undergoing emergency appendicectomy over a 24-month period at a large teaching hospital. Hyperbilirubinaemia was defined as >25 µmol/L. Data were analysed using descriptive statistics. RESULTS 484 of the 557 (86.9 %) operated cases were found histologically to be appendicitis. 116 cases of the 484 were perforated (24 %). Bilirubin levels were significantly higher in the group with appendicitis versus the group found to have a normal appendix at histology, [median (IQR) 12.0 µmol/L (9.00) vs. 8.0 µmol/L (7.00) respectively, p < 0.001], despite being within normal serum bilirubin range. Sensitivity of hyperbilirubinaemia for acute appendicitis was only 8 %, however specificity was 94 %. PPV was 85 % and NPV was 26 %. Whilst bilirubin was higher in patients with a perforated appendix versus acute appendicitis [median (IQR) 13.0 µmol/L (9.00) vs. 11.0 µmol/L (9.00), respectively], statistically, there was no significant difference in pre-operative bilirubin levels between the perforated appendicitis cases and the non-perforated appendicitis cases (p = 0.326). However, the specificity of hyperbilirubinaemia for perforated appendicitis was 93 %, sensitivity 9.4 %, PPV 24 % and NPV 82 %. CONCLUSION Bilirubin levels may be high, but remain within normal range, in cases of appendicitis. Therefore, bilirubin levels may be a useful measurement when investigating a patient with suspected appendicitis. Hyperbilirubinaemia is highly specific with regards to perforation, a finding supported by other studies. However, possibly because of the few perforated cases in this study, we cannot recommend that hyperbilirubinaemia be used to predict perforation.
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Affiliation(s)
- H L Adams
- Warwickshire Surgical Research Group, Warwickshire, UK.
| | - S S Jaunoo
- Warwickshire Surgical Research Group, Warwickshire, UK
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30
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Ademola TO, Oludayo SA, Samuel OA, Amarachukwu EC, Akinwunmi KO, Olusanya A. Clinicopathological review of 156 appendicectomies for acute appendicitis in children in Ile-Ife, Nigeria: a retrospective analysis. BMC Emerg Med 2015; 15:7. [PMID: 25956068 PMCID: PMC4445528 DOI: 10.1186/s12873-015-0030-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2014] [Accepted: 03/03/2015] [Indexed: 12/18/2022] Open
Abstract
Background Acute appendicitis is one of the most common causes of acute abdomen in children. Late surgical intervention is often associated with increase morbidity and sometimes fatal outcome. We sought to determine the pattern of presentation of acute appendicitis, and the effect of late presentation on surgical outcome in children. Methods This is a retrospective descriptive study done at the paediatric surgical unit of Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife, Nigeria. The hospital records of all 180 patients (15 years and below) treated for acute appendicitis, between January 1995 and December 2012, were reviewed; only 156 patients had adequate records out of which 139 cases confirmed histologically as having appendicitis were analyzed. Results There were 80 (57.6%) females and 59 (42.4%) males. The age range was 5-15years with mean (SD) age of 11.2 (±2.9) years. Most patients (64.7%) were more than 10 years old. Sixty-four (46%) patients had simple appendicitis while 75 (54%) patients had complicated appendicitis. More children with complicated appendicitis (63, 84.0%) presented after 24 hours of abdominal pain; and they had more vomiting (59, 78.7%), spent longer days on admission (57, 76.0%) and had more post- operative complications (34, 45.3%) compared with uncomplicated appendicitis (25, 39.1%; 29, 45.3%; 7, 10.9%; 1, 1.6% respectively), and this was statistically significant (p < 0.05). No mortality was recorded among these children. Conclusion Late presentation was common and was associated with longer duration of hospital stay and high morbidity. No mortality was recorded from the disease.
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Affiliation(s)
- Talabi O Ademola
- Department of Surgery, Obafemi Awolowo University/Obafemi Awolowo University Teaching Hospital, Ile-Ife, Nigeria.
| | - Sowande A Oludayo
- Department of Surgery, Obafemi Awolowo University/Obafemi Awolowo University Teaching Hospital, Ile-Ife, Nigeria.
| | - Olowookere A Samuel
- Department of Community Health, Obafemi Awolowo University, Ile-Ife, Nigeria.
| | - Etonyeaku C Amarachukwu
- Department of Surgery, Obafemi Awolowo University/Obafemi Awolowo University Teaching Hospital, Ile-Ife, Nigeria.
| | - Komolafe O Akinwunmi
- Department of Morbid Anatomy and Forensic Medicine, Obafemi Awolowo University, Ile-Ife, Nigeria.
| | - Adejuyigbe Olusanya
- Department of Surgery, Obafemi Awolowo University/Obafemi Awolowo University Teaching Hospital, Ile-Ife, Nigeria.
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31
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Shogilev DJ, Duus N, Odom SR, Shapiro NI. Diagnosing appendicitis: evidence-based review of the diagnostic approach in 2014. West J Emerg Med 2014; 15:859-71. [PMID: 25493136 PMCID: PMC4251237 DOI: 10.5811/westjem.2014.9.21568] [Citation(s) in RCA: 128] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2014] [Revised: 07/29/2014] [Accepted: 09/02/2014] [Indexed: 12/29/2022] Open
Abstract
Introduction Acute appendicitis is the most common abdominal emergency requiring emergency surgery. However, the diagnosis is often challenging and the decision to operate, observe or further work-up a patient is often unclear. The utility of clinical scoring systems (namely the Alvarado score), laboratory markers, and the development of novel markers in the diagnosis of appendicitis remains controversial. This article presents an update on the diagnostic approach to appendicitis through an evidence-based review. Methods We performed a broad Medline search of radiological imaging, the Alvarado score, common laboratory markers, and novel markers in patients with suspected appendicitis. Results Computed tomography (CT) is the most accurate mode of imaging for suspected cases of appendicitis, but the associated increase in radiation exposure is problematic. The Alvarado score is a clinical scoring system that is used to predict the likelihood of appendicitis based on signs, symptoms and laboratory data. It can help risk stratify patients with suspected appendicitis and potentially decrease the use of CT imaging in patients with certain Alvarado scores. White blood cell (WBC), C-reactive protein (CRP), granulocyte count and proportion of polymorphonuclear (PMN) cells are frequently elevated in patients with appendicitis, but are insufficient on their own as a diagnostic modality. When multiple markers are used in combination their diagnostic utility is greatly increased. Several novel markers have been proposed to aid in the diagnosis of appendicitis; however, while promising, most are only in the preliminary stages of being studied. Conclusion While CT is the most accurate mode of imaging in suspected appendicitis, the accompanying radiation is a concern. Ultrasound may help in the diagnosis while decreasing the need for CT in certain circumstances. The Alvarado Score has good diagnostic utility at specific cutoff points. Laboratory markers have very limited diagnostic utility on their own but show promise when used in combination. Further studies are warranted for laboratory markers in combination and to validate potential novel markers.
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Affiliation(s)
- Daniel J Shogilev
- Duke University, Division of Emergency Medicine, Duke University, Durham, North Carolina
| | - Nicolaj Duus
- Beth Israel Deaconess Medical Center, Department of Emergency Medicine, Boston, Massachusetts
| | - Stephen R Odom
- Beth Israel Deaconess Medical Center, Department of Surgery, Boston, Massachusetts
| | - Nathan I Shapiro
- Beth Israel Deaconess Medical Center, Department of Emergency Medicine and Center for Vascular Biology, Boston, Massachusetts
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Teo ATK, Lefter LP, Zarrouk AJM, Merrett ND. Institutional review of patients presenting with suspected appendicitis. ANZ J Surg 2014; 85:420-4. [PMID: 24640953 DOI: 10.1111/ans.12531] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/26/2013] [Indexed: 12/29/2022]
Abstract
BACKGROUND Appendicitis is a common gastrointestinal surgical emergency. Treatment balances the risks of negative appendicectomy (NA) against potential complicated appendicitis in determining clinical priority. This study reviewed the population characteristics, results of the diagnostic modalities and Alvarado score (AlvS) of patients with suspected appendicitis. METHODS A clinical audit of emergency appendicectomies was performed. Generalized linear models with a binomial distribution were used to evaluate the association between the age groups, gender, white cell count (WCC), neutrophil count (NC) and C-reactive protein (CRP) levels versus NAs and the different types of appendicitis. The utilization and accuracy of preoperative ultrasound and computed tomography (CT) and a preliminary analysis of AlvS were also evaluated. RESULTS Patients 17 to 24 years old had significantly higher odds of NA but lower odds of complicated appendicitis compared with patients above 40 years. Adult women and men had significantly higher odds of NA and suppurative appendicitis (SA), respectively. Only adults with SA and acute appendicitis had significantly higher odds of raised WCC, NC and CRP. The sensitivity of CT for adult females was high (100%). Patients who had CT and an AlvS of more than 7 did not have NAs. CONCLUSION Elevated WCC, NC and CRP were all associated with acute appendicitis and SA in adults only. CT is useful for refining the diagnosis in adult females. A combination of inflammatory markers, ultrasound and AlvS may be used selectively to complement or maximize the advantages of CT.
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Affiliation(s)
- Andrew Teck Kwee Teo
- Department of Surgery, Campbelltown Hospital, Sydney, New South Wales, Australia
| | - Liviu Paul Lefter
- Department of Surgery, Campbelltown Hospital, Sydney, New South Wales, Australia
| | | | - Neil Donald Merrett
- Department of Surgery, Campbelltown Hospital, Sydney, New South Wales, Australia.,Department of Surgery, University of Western Sydney, Sydney, New South Wales, Australia
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Nomura S, Watanabe M, Komine O, Shioya T, Toyoda T, Bou H, Shibuya T, Suzuki H, Uchida E. Serum total bilirubin elevation is a predictor of the clinicopathological severity of acute appendicitis. Surg Today 2013; 44:1104-8. [PMID: 23880964 DOI: 10.1007/s00595-013-0659-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2013] [Accepted: 06/03/2013] [Indexed: 01/26/2023]
Abstract
PURPOSE Elevation of the serum total bilirubin (STB) level not stemming from hepatic dysfunction or biliary obstruction may be seen in cases of acute appendicitis. This paper deals with the clinical significance of such elevations. METHODS Data from 410 appendectomized patients classified into two groups (a high preoperative STB group and a normal preoperative STB group) were analyzed to reveal the significance of preoperative hyperbilirubinemia. We also examined whether the preoperative STB level might serve as a risk factor for gangrenous appendicitis by a multivariate analysis. RESULTS Gangrenous appendicitis was more common in the high preoperative STB group (p < 0.001). The multivariate analysis revealed that an elevated preoperative STB level (odds ratio 1.7919) was a risk factor for gangrenous appendicitis. CONCLUSION In patients with an elevated preoperative STB level, it is very likely that the inflammation is severe and that the disease has progressed to a severe condition histopathologically; therefore, meticulous attention should be paid to the selection of the surgical procedure, as well as to the postoperative clinical course.
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Affiliation(s)
- Satoshi Nomura
- Institute of Gastroenterology, Nippon Medical School Musashi Kosugi Hospital, 1-396, Kosugi-cho, Nakahara-ku, Kawasaki, Kanagawa, 211-8533, Japan
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Abstract
During the past two decades, the incidence of childhood obesity has increased at alarming rates throughout the world. Obesity is associated with a variety of physiological changes that may impair a patient's response to surgery. With the rising rates of childhood obesity, pediatric surgeons must appreciate differences in the management and outcomes of these patients. Difficult physical examination, elevated inflammatory blood markers, and negative influence of obesity on the detection rate of the appendix on ultrasound have been reported causing diagnostic challenging of appendicitis in obese children. Moreover, obesity is associated with longer hospital stay and higher morbidity and minimal invasive techniques' superior outcomes over open technique in children undergoing appendectomy.
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Affiliation(s)
- Balazs Kutasy
- National Children's Research Center, Our Lady's Children's Hospital, Dublin, Ireland.
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Aguiar FJ, Ferreira-Júnior M, Sales MM, Cruz-Neto LM, Fonseca LA, Sumita NM, Duarte NJ, Lichtenstein A, Duarte AJ. Proteína C reativa: aplicações clínicas e propostas para utilização racional. Rev Assoc Med Bras (1992) 2013. [DOI: 10.1590/s0104-42302013000100016] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Role of mean platelet volume in diagnosis of childhood acute appendicitis. Emerg Med Int 2012; 2012:823095. [PMID: 22970376 PMCID: PMC3434375 DOI: 10.1155/2012/823095] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2012] [Revised: 07/12/2012] [Accepted: 07/24/2012] [Indexed: 12/12/2022] Open
Abstract
Introduction. Acute appendicitis is the leading cause of abdominal pain in children requiring emergency surgical intervention. The aim of this study is to investigate the diagnostic value of MPV in early diagnosis of acute appendicitis cases in pediatric age group. Methods. This study was performed retrospectively. Three hundred five patients operated on with the diagnosis of appendicitis and pathologically found to be acute appendicitis were classified as Group 1 and 305 healthy children were classified as control Group 2. Results. One hundred ninety-seven of 305 cases in Group 1 are males (64.6%), in Group 2, 151 of 305 cases are males (49.5%). The mean MPV in Group 1 was 7.9 ± 0.9
(fL), and whereas in Group 2 was 7.7 ± 0.8
(fL). There was no statistically significant difference regarding MPV values (P > 0.05). Conclusion. In our study we detected that mean platelet volume has no diagnostic value in pediatric acute appendicitis cases.
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Correlation of serum C-reactive protein, white blood count and neutrophil percentage with histopathology findings in acute appendicitis. World J Emerg Surg 2012; 7:27. [PMID: 22866907 PMCID: PMC3469372 DOI: 10.1186/1749-7922-7-27] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2012] [Accepted: 07/31/2012] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Acute appendicitis is one of the most common surgical emergencies. Accurate diagnosis of acute appendicitis is based on careful history, physical examination, laboratory and imaging investigation. The aim of the study is to analyze the role of C-reactive protein (CRP), white blood count (WBC) and Neutrophil percentage (NP) in improving the accuracy of diagnosis of acute appendicitis and to compare it with the intraoperative assessment and histopathology findings. MATERIALS AND METHODS This investigation was a prospective double blinded clinical study. The study was done on 173 patients surgically treated for acute appendicitis. The WBC, NP, and measurement of CRP were randomly collected pre-operatively from all involved patients. Macroscopic assessment was made from the operation. Appendectomy and a histopathology examination were performed on all patients. Gross description was compared with histopathology results and then correlated with CRP, WBC, and NP. RESULTS The observational accuracy was 87,3%, as compared to histopathological accuracy which was 85.5% with a total of 173 patients that were operated on. The histopathology showed 25 (14.5%) patients had normal appendices, and 148 (85.5%) patients had acutely inflamed, gangrenous, or perforated appendicitis. 52% were male and 48% were female, with the age ranging from 5 to 59 with a median of 19.7. The gangrenous type was the most frequent (52.6%). The WBC was altered in 77.5% of the cases, NP in 72.3%, and C-reactive protein in 76.9% cases. In those with positive appendicitis, the CRP and WBC values were elevated in 126 patients (72.8%), whereas NP was higher than 75% in 117 patients (67.6%). Out of 106 patients with triple positive tests, 101 (95.2%) had appendicitis. The sensitivity, specificity, and positive predictive values of the 3 tests in combination were 95.3%, 72.2%, and 95.3%, respectively. CONCLUSION The raised value of the CRP was directly related to the severity of inflammation (p-value <0.05). CRP monitoring enhances the diagnostic accuracy of acute appendicitis. The diagnostic accuracy of CRP is not significantly greater than WBC and NP. A combination of these three tests significantly increases the accuracy. We found that elevated serum CRP levels support the surgeon's clinical diagnosis.
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Bröker ME, van Lieshout EM, van der Elst M, Stassen LP, Schepers T. Discriminating Between Simple and Perforated Appendicitis. J Surg Res 2012; 176:79-83. [DOI: 10.1016/j.jss.2011.09.049] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2011] [Revised: 08/17/2011] [Accepted: 09/22/2011] [Indexed: 01/30/2023]
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Abstract
OBJECTIVES The objective was to describe the association between two novel biomarkers, calprotectin and leucine-rich alpha glycoprotein-1 (LRG), and appendicitis in children. METHODS This was a prospective, cross-sectional study of children 3 to 18 years old presenting to a pediatric emergency department (ED) with possible appendicitis. Blood and urine samples were assayed for calprotectin and LRG via enzyme-linked immunosorbent assay (ELISA). Final diagnosis was determined by histopathology or telephone follow-up. Biomarker levels were compared for subjects with and without appendicitis. Recursive partitioning was used to identify thresholds that predicted appendicitis. RESULTS Of 176 subjects, mean (±SD) age was 11.6 (±4.0) years and 52% were male. Fifty-eight patients (34%) were diagnosed with appendicitis. Median plasma calprotectin, serum LRG, and urine LRG levels were higher in appendicitis versus nonappendicitis (p < 0.008). When stratified by perforation status, median plasma calprotectin and serum LRG levels were higher in nonperforated appendicitis versus nonappendicitis (p < 0.01). Median serum LRG, urine LRG, and plasma calprotectin levels were higher in perforated appendicitis compared to nonperforated appendicitis (p < 0.05). Urine calprotectin did not differ among groups. A serum LRG < 40,150 ng/mL, a urine LRG < 42 ng/mL, and a plasma calprotectin < 159 ng/mL, each provided a sensitivity and negative predictive value of 100% to identify children at low risk for appendicitis, but with specificities ranging from 23% to 35%. The standard white blood cell (WBC) count achieved 100% sensitivity at a higher specificity than both novel biomarkers. CONCLUSIONS Plasma calprotectin and serum/urine LRG are elevated in pediatric appendicitis. No individual marker performed as well as the WBC count.
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Affiliation(s)
- Anupam B Kharbanda
- Division of Pediatric Emergency Medicine, Columbia University College of Physicians and Surgeons, New York, NY, USA.
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Atahan K, Üreyen O, Aslan E, Deniz M, Çökmez A, Gür S, Avci A, Tarcan E. Preoperative diagnostic role of hyperbilirubinaemia as a marker of appendix perforation. J Int Med Res 2011; 39:609-18. [PMID: 21672366 DOI: 10.1177/147323001103900230] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
This retrospective study investigated preoperative markers of appendix perforation in 351 acute appendicitis cases: group 1, appendicitis not histologically confirmed; group 2, appendicitis without perforation or gangrenous changes; and group 3, histologically confirmed perforated appendicitis with gangrenous changes. In group 3, symptom duration was significantly longer, and white blood cell (WBC) and bilirubin values significantly higher, than for the other groups. Symptom duration, gender, bilirubin and elevated WBC were significantly associated with early diagnosis of acute appendicitis in univariate analysis. Multivariate analysis identified increased WBC counts and male gender as independent variables for the early diagnosis of acute suppurative appendicitis, and symptom duration, total bilirubin and elevated WBC as independent variables for identifying appendix perforation amongst acute suppurative appendicitis patients. Receiver operating characteristic curve analysis showed good discrimination of bilirubin and moderate discrimination of WBC as markers of appendix perforation. It is concluded that assessment of preoperative total bilirubin is useful for the differential diagnosis of perforated versus acute suppurative appendicitis, whereas WBC assessment is effective for diagnosing the presence versus absence of appendicitis. Symptom duration, WBC and total bilirubin should be used as independent parameters in the early diagnosis of appendix perforation.
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Affiliation(s)
- K Atahan
- First Surgical Department, İzmir Atatürk Training and Research Hospital, İzmir, Turkey.
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Siddique K, Baruah P, Bhandari S, Mirza S, Harinath G. Diagnostic accuracy of white cell count and C-reactive protein for assessing the severity of paediatric appendicitis. JRSM SHORT REPORTS 2011; 2:59. [PMID: 21847441 PMCID: PMC3147235 DOI: 10.1258/shorts.2011.011025] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVES Simple investigations like white cell count (WCC) and C-reactive protein (CRP) may help to improve the accuracy of diagnosis in paediatric appendicitis. We evaluated the diagnostic accuracy of WCC and CRP for the severity of acute appendicitis in children. DESIGN Cross-sectional study. SETTING This study was conducted on all children who underwent open appendectomy from January 2007 to December 2008 at a District General Hospital. Data regarding demographics, WCC, CRP, histology and postoperative complications were analysed. PARTICIPANTS All children who underwent open appendectomy during the study period. MAIN OUTCOME MEASURES Diagnostic accuracy of WCC and CRP for simple acute appendicitis and a perforated appendix. RESULTS Out of 204 patients, 112 (54.9%) were girls. At surgery, appendix was grossly inflamed in 175 of which 32 had perforation. Histology revealed simple acute appendicitis in 135 (66.2%) and gangrenous appendicitis in 32 (15.7%). The rest were normal. The duration of symptoms, temperature, length of stay, WCC and CRP were significantly worse in the perforated group (P value <0.05). Postoperative complications included wound infection (n = 18), pelvic collection (n = 5) and intestinal obstruction (n = 6); and were more common among patients with a perforated appendix (P value <0.05). WCC had a higher diagnostic accuracy and higher sensitivity than CRP in diagnosing simple acute appendicitis. The combined sensitivity of WCC and CRP increased to 95% and 100% for the diagnosis of simple acute appendicitis and a perforated appendix, respectively. CONCLUSION Accuracy of WCC is higher than CRP for diagnosing simple acute appendicitis. The combined sensitivity of WCC and CRP increases for simple acute appendicitis as well as a perforated appendix.
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Affiliation(s)
- Khurram Siddique
- Department of General Surgery, William Harvey Hospital, Ashford, Kent, UK
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Abstract
Abdominal pain in older adults is a concerning symptom common to a variety of diagnoses with high morbidity and mortality. Organizing the differential into categories based on pathology (inflammatory, obstructive, vascular, or other causes) provides a framework for the history, physical, and diagnostic studies. An organized approach and treatment and considerations specific to the geriatric population are discussed.
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Affiliation(s)
- Luna Ragsdale
- Division of Emergency Medicine, Duke University Medical Center, Durham, NC 27710, USA.
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Serum Markers in Acute Appendicitis. J Surg Res 2011; 168:70-5. [DOI: 10.1016/j.jss.2009.10.029] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2009] [Revised: 09/01/2009] [Accepted: 10/19/2009] [Indexed: 12/22/2022]
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Tsai TC, Wong LY, Wu HP. Ovarian torsion caused by teratoma masquerading as perforated appendicitis in a 5-year-old girl. Pediatr Neonatol 2011; 52:51-4. [PMID: 21385659 DOI: 10.1016/j.pedneo.2010.12.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2009] [Revised: 11/19/2009] [Accepted: 02/26/2010] [Indexed: 01/01/2023] Open
Abstract
Ovarian torsion is a well-known but poorly recognized disease. Although ovarian torsion is the most common complication of ovarian tumors in children, it is an uncommon cause of abdominal pain in pediatric patients. Ovaries can be only salvaged by prompt diagnosis and timely surgical intervention. Acute ovarian torsion without appropriate treatment may result in loss of ovarian function, tissue necrosis, and death. The objective of this article is to present a case of pediatric ovarian torsion and describe the difficulty of distinguishing it from perforated appendicitis in the emergency department (ED). We report a 5-year-old girl who presented to the ED with nausea, tenderness over the right lower guardant of her abdomen, fever, and anorexia. She was initially diagnosed with appendicitis based on physical examination and abdominal computed tomography scan and was sent to the operating room for surgical exploration. The definite diagnosis of the patient was acute ovarian torsion complicated with cystic teratoma. Primary clinicians in the ED should pay more attention to acute ovarian torsion in young children because it is difficult to diagnose in time to salvage the gynecological function when the clinical presentations masquerade as perforated appendicitis.
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Affiliation(s)
- Tzu-Chun Tsai
- Department of Medical Research and Education, National Yang-Ming University Hospital, Yilan, Taiwan
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Kim HC, Yang DM, Lee CM, Jin W, Nam DH, Song JY, Kim JY. Acute appendicitis: relationships between CT-determined severities and serum white blood cell counts and C-reactive protein levels. Br J Radiol 2010; 84:1115-20. [PMID: 21123307 DOI: 10.1259/bjr/47699219] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
OBJECTIVES The aim of this study was to evaluate the relationships between the severity of appendicitis as depicted on CT and blood inflammatory markers of serum white blood cell (WBC) count and C-reactive protein (CRP). METHODS CT images in 128 patients (109 surgically proven and 19 with clinically excluded appendicitis) were retrospectively reviewed. Two radiologists by consensus evaluated and scored (using a 0, 1 or 2 point scale) severities based on CT-determined appendiceal diameters, appendiceal wall changes, caecal changes, periappendiceal inflammatory stranding and phlegmon or abscess formation. We investigated whether CT findings were significantly related to elevated WBC counts or CRP levels and performed the correlations of WBC counts and CRP levels with CT severity scores. Patients were also subjectively classified using four grades from normal (Grade I) to perforated appendicitis (Grade IV) on the basis of CT findings to evaluate differences in WBC counts and CRP levels between grades. RESULTS Only appendiceal wall changes and the phlegmon or abscess formation were related to elevated WBC counts and CRP levels, respectively (p<0.05). CT severity scores were found to be more strongly correlated with CRP levels (r = 0.669) than with WBC counts (r = 0.222). On the basis of CT grades, the WBC counts in Grade I were significantly lower than in other grades (p<0.001), whereas CRP levels in Grade IV were significantly higher than in other grades (p<0.001). CONCLUSION CRP levels were found to correlate with CT-determined acute appendicitis severity and could be a useful predictor for perforated appendicitis, whereas WBC counts might be useful to detect early acute appendicitis.
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Affiliation(s)
- H C Kim
- Department of Radiology, East-West Neo Medical Centre, Kyung Hee University, Seoul, Republic of Korea.
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Abstract
PURPOSE The diagnosis of acute appendicitis by physical examination can sometimes be difficult in extremely obese children. C-reactive protein (CRP) is commonly used to support the clinical diagnosis of appendicitis. However, obesity has been widely recognized as a chronic inflammatory condition and associated with elevated inflammatory indicators including CRP. The aim of this study was to examine the association between obesity and CRP levels in extremely obese children presenting with suspected appendicitis. MATERIALS The hospital records of 947 consecutive patients, who underwent appendectomy for acute appendicitis between 2002 and 2008 were retrospectively analyzed. 164 children (17.3%) were extremely obese. Extreme obesity was defined, as greater than two standard deviations above the standardized mean weight for age. The diagnostic value of CRP level was compared between extremely obese and non-obese children. RESULTS The incidence of histologically normal appendix was significantly higher in extremely obese children [42 out of 164 (25.6%)] compared to non-obese children [85 out of 783 (10.8%) (P < 0.001)]. The mean CRP levels were significantly higher in extremely obese children with histologically normal appendix compared to non-obese children with normal appendix (P < 0.001). The specificity and the positive predictive value were significantly lower in the extremely obese children group than in the non-obese group (P < 0.001). CONCLUSION CRP is not a reliable marker of inflammation in extremely obese children presenting with suspected appendicitis. Our data highlight the importance of obesity when interpreting the significance of an elevated CRP level in children with suspected diagnosis of appendicitis.
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An evaluation of the utility of additional tests in the preoperative diagnostics of acute appendicitis. Langenbecks Arch Surg 2009. [PMID: 19924436 DOI: 10.1007/s00423-009-0565-x.epub] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Determining the optimum algorithm for diagnostic procedure in suspected acute appendicitis (AA) may not only reduce the number of unnecessary operations, but also the frequency of complications, and may contribute measurably to reducing the costs of treating patients with acute abdominal conditions. OBJECTIVE The aim of the study was to assess the value of standard diagnostic methods and measurement of selected biochemical and hematological parameters (C-reactive protein, CRP; interleukin-6, IL-6; procalcitonin, PCT; total count of white blood cell, WBC) in the accuracy of preoperative AA diagnosis. MATERIAL AND METHODS The prospective study included 132 patients (female: 52.3%, male: 47.7%) emergency admitted to the Surgical Department, aged 15 to 74 years (mean 36 years), with a suspicion of appendicitis. Measurement of PCT concentration was carried out by immunoluminometric assay, IL-6 concentration by micro enzyme-linked immunosorbent assay and CRP concentration by immunonephelometric assay. Statistical analysis was done by the chi-square test and Fisher's exact test for categorized discrete variables, and the Mann-Whitney U and Kruskal-Wallis tests for continuous variables. In order to assay the diagnostic utility of tests, the receiver operating characteristic model of curve analysis was used. RESULTS AA was confirmed in 89 (67.5%) of the patients operated on (group A). Twenty-six (19.7%) of the patients were not operated on and did not require surgery (group C); in 13 patients (9.8%) operated with a preliminary diagnosis of AA, no changes in the appendix were found during the course of the operation (group B). Four (3%) of the patients treated conservatively for periappendicular infiltration were excluded from the following analysis (group D). The mean count of WBC in AA was 13.22 ± 4.45 × 103/μL, with no statistical significance between groups, which does not allow the patients requiring surgery to be distinguished. The highest elevation of IL-6 concentration was observed in the group with the AA and the periappendicular infiltration: 101.5 ± 355.9 vs. 173.6 ± 228.33 pg/mL, respectively; p < 0.05. No surgery patients of group C showed considerably lower CRP concentrations than those of group D: CRP: 2.05 ± 3.6 vs. 6.36 ± 4.74 mg/L; p < 0.05. In cases of advanced forms of AA, the gangrenous with perforation, higher marker values are obtained than those in the phlegmonose form (186.60 ± 541.2 vs. 40.08 ± 48.3 pg/mL; (p < 0.05) for IL-6 and 8.88 ± 7.45 vs. 2.84 ± 3.83 mg/L; (p < 0.001) for CRP, respectively). CONCLUSIONS 1. AA diagnosis based only on an assessment of clinical status may lead to an increase in the number of people operated with false-positive diagnoses of AA. 2. Applying additional diagnostic methods such as IL-6 determination seems to be useful in reducing the numbers of false-positive diagnoses of AA. 3. Laboratory tests, i.e., CRP, IL-6, and PCT are much more useful in assessing the risk of complications during the course of AA.
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An evaluation of the utility of additional tests in the preoperative diagnostics of acute appendicitis. Langenbecks Arch Surg 2009; 395:1061-8. [PMID: 19924436 DOI: 10.1007/s00423-009-0565-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2009] [Accepted: 10/16/2009] [Indexed: 12/29/2022]
Abstract
BACKGROUND Determining the optimum algorithm for diagnostic procedure in suspected acute appendicitis (AA) may not only reduce the number of unnecessary operations, but also the frequency of complications, and may contribute measurably to reducing the costs of treating patients with acute abdominal conditions. OBJECTIVE The aim of the study was to assess the value of standard diagnostic methods and measurement of selected biochemical and hematological parameters (C-reactive protein, CRP; interleukin-6, IL-6; procalcitonin, PCT; total count of white blood cell, WBC) in the accuracy of preoperative AA diagnosis. MATERIAL AND METHODS The prospective study included 132 patients (female: 52.3%, male: 47.7%) emergency admitted to the Surgical Department, aged 15 to 74 years (mean 36 years), with a suspicion of appendicitis. Measurement of PCT concentration was carried out by immunoluminometric assay, IL-6 concentration by micro enzyme-linked immunosorbent assay and CRP concentration by immunonephelometric assay. Statistical analysis was done by the chi-square test and Fisher's exact test for categorized discrete variables, and the Mann-Whitney U and Kruskal-Wallis tests for continuous variables. In order to assay the diagnostic utility of tests, the receiver operating characteristic model of curve analysis was used. RESULTS AA was confirmed in 89 (67.5%) of the patients operated on (group A). Twenty-six (19.7%) of the patients were not operated on and did not require surgery (group C); in 13 patients (9.8%) operated with a preliminary diagnosis of AA, no changes in the appendix were found during the course of the operation (group B). Four (3%) of the patients treated conservatively for periappendicular infiltration were excluded from the following analysis (group D). The mean count of WBC in AA was 13.22 ± 4.45 × 103/μL, with no statistical significance between groups, which does not allow the patients requiring surgery to be distinguished. The highest elevation of IL-6 concentration was observed in the group with the AA and the periappendicular infiltration: 101.5 ± 355.9 vs. 173.6 ± 228.33 pg/mL, respectively; p < 0.05. No surgery patients of group C showed considerably lower CRP concentrations than those of group D: CRP: 2.05 ± 3.6 vs. 6.36 ± 4.74 mg/L; p < 0.05. In cases of advanced forms of AA, the gangrenous with perforation, higher marker values are obtained than those in the phlegmonose form (186.60 ± 541.2 vs. 40.08 ± 48.3 pg/mL; (p < 0.05) for IL-6 and 8.88 ± 7.45 vs. 2.84 ± 3.83 mg/L; (p < 0.001) for CRP, respectively). CONCLUSIONS 1. AA diagnosis based only on an assessment of clinical status may lead to an increase in the number of people operated with false-positive diagnoses of AA. 2. Applying additional diagnostic methods such as IL-6 determination seems to be useful in reducing the numbers of false-positive diagnoses of AA. 3. Laboratory tests, i.e., CRP, IL-6, and PCT are much more useful in assessing the risk of complications during the course of AA.
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Children Presenting at the Emergency Department With Right Lower Quadrant Pain. Kaohsiung J Med Sci 2009; 25:1-9. [PMID: 19289311 DOI: 10.1016/s1607-551x(09)70033-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
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