Predictive value of white blood cell count and C-reactive protein in children with appendicitis

Appendicitis in Children: Does Age Really Matter?

BACKGROUND

Acute appendicitis (AA) is a frequent and emergent surgical abdominal condition that presents some particularities and challenges in young children.

PATIENTS AND METHODS

Data of 402 children aged <16 years with a confirmed diagnosis of AA were retrospectively reviewed. Included patients were divided into two groups: Group A (preschool children aged ≤5 years, n = 44) and Group B (school children aged >5 years, n = 358). Clinical presentation, biological findings, calculated diagnosis scores (paediatric appendicitis score [PAS] and Alvarado score), intraoperative findings and outcomes were comparatively analysed between the two groups.

RESULTS

Children of Group A had more likely fever, bowel disorders, diffuse abdominal pain and diffuse tenderness than those of Group B (P = 0.001, P = 0.005, P = 0.006 and P = 0.001, respectively). Regarding biomarkers, the mean of white blood cell count and C-reactive protein levels was higher in Group A than in Group B (18,849 cell/mm3 and 162.8 mg/L in Group A versus 15,938 cell/mm3 and 86.7 mg/L in Group B, P = 0.003 and < 0.001, respectively). The mean of calculated PAS and Alvarado scores was higher in Group A than in Group B (8.2 ± 1.1 and 8.2 ± 1 vs. 7.5 ± 1.4 and 7.4 ± 1.5, P = 0.003 and P = 0.001, respectively). Most children with a calculated PAS and Alvarado score equal to or higher than 8 belonged to Group A (PAS: 84.1% vs. 58.4%, P = 0.001, Alvarado score: 84.1% vs. 55.6%, P < 0.001). The perforation of the appendix was seen in 77.3% of Group A patients and only in 41.5% of children in Group B (P < 0.0001). The mean length of stay was 5.1 ± 1.9 days in Group A and 4.3 ± 2.8 days in Group B but without any statistical difference between the two groups (P = 0.094).

CONCLUSION

AA in preschool children is associated with atypical presentation and rapid progression of the disease making the early diagnosis mostly challenging in our settings.

Uncomplicated appendicitis at Herat Regional Hospital: limited resource is not always the end of the world

BACKGROUND

Acute appendicitis is the most common aetiology of acute abdomen in children. Our aim is to describe the accuracy of diagnosis, and complications in a limited resources setting in children between 5 and 14 years old at the only tertiary referral hospital in the West region of Afghanistan.

METHODS

A retrospective study for a period of 1 year (21 March 2015-20 March 2016). Data was collected from patients' files. Data were analysed by epi info 7.

RESULTS

We identified 774 children who had appendectomies at Herat Regional Hospital during the study period with complete records available for analysis. The median age was 11 years [5-14]. The rate of positive appendectomy was 87%. 72% of appendectomies were done within 24 h of the onset of symptoms. Of 675 positive appendectomies, the most common clinical features were migratory abdominal pain (90%), nausea/vomiting (80%), RLQ tenderness (90%), and rebound tenderness (81%). Among the 99 negative appendectomies, the most common signs and symptoms were anorexia 68%, nausea/vomiting 59%, RLQ tenderness 79%, and rebound tenderness 43%. 98% of positive and 71% of negative appendectomies had elevated WBC count. Post appendectomy complications occurred in 9% of our patients mostly commonly intra-abdominal abscesses (5%).

CONCLUSION

Although the diagnosis of acute appendicitis is challenging in children and may involve sophisticated imaging techniques, in many settings these are unavailable. Classical manifestations such as migratory abdominal pain, abdominal tenderness, nausea, and simple lab tests play a crucial role in the diagnosis of acute appendicitis in low resource environments.

Serum matrix metalloproteinase-7 for discriminating biliary atresia: a diagnostic accuracy and validation study

BACKGROUND

Prompt and precise differential diagnosis of biliary atresia (BA) among cholestatic patients is of great importance. Matrix metalloproteinase-7 (MMP-7) holds great promise as a diagnostic marker for BA. This study aimed to investigate the accuracy of age-specific serum MMP-7 for discriminating BA from other cholestatic pediatric patients.

METHODS

This was a single center diagnostic accuracy and validation study including both retrospective and prospective cohorts. Serum MMP-7 concentrations were measured using an ELISA kit, the trajectory of which with age was investigated in a healthy infants cohort aged 0 to 365 days without hepatobiliary diseases (n = 284). Clinical BA diagnosis was based on intraoperative cholangiography and subsequent histological examinations. The diagnostic accuracy of age-specific cutoffs of serum MMP-7 were assessed in a retrospective cohort of cholestatic patients (n = 318, with 172 BA) and validated in a prospective cohort (n = 687, including 395 BA).

RESULTS

The MMP-7 concentration declines non-linearly with age, showing higher levels in healthy neonates as well as higher cutoff value in neonatal cholestasis. The area under the ROC curve (AUROC) was 0.967 (95% confidence interval [CI]: 0.946-0.988) for the retrospective cohort, and the cutoff of 18 ng/mL yielded 93.0% (95%CI: 88.1-96.3%), 93.8% (95%CI: 88.6-97.1%), 94.7% (95%CI: 90.1-97.5%), and 91.9% (95%CI: 86.4-95.8%) for sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV), respectively. The performance of MMP-7 was successfully validated in the larger prospective cohort, resulting in a diagnostic sensitivity of 95.9% (379/395; 95% CI: 93.5-97.7%), a specificity of 87.3% (255/292; 95% CI: 83.0-90.9%), a PPV of 91.1% (379/416; 95% CI: 87.9-93.7%), and a NPV of 94.1% (255/271; 95% CI: 90.6-96.6%), respectively. Besides, higher cutoff value of 28.1 ng/mL achieved the best sensitivity, specificity, PPV, and NPV for infants aged 0-30 days, which was 86.4% (95% CI: 75.0-94.0%), 95.5% (95% CI: 77.2-99.9%), 98.1% (95% CI: 89.7-100%), and 72.4% (95% CI: 52.8-87.3%), respectively.

CONCLUSIONS

The serum MMP-7 is accurate and reliable in differentiating BA from non-BA cholestasis, showing its potential application in the diagnostic algorithm for BA and significant role in the future research regarding pathogenesis of BA.

The Predictive Value of Plasma Sodium and Other Laboratory Parameters in Determining Complicating Appendicitis in Children

OBJECTIVE

Finding a reliable preoperative predictor of complicated acute appendicitis (AA) has been a challenging diagnostic problem. The present study aimed to identify potential factors that may predict complicated AA in the pediatric emergency department (ED) based on routine, widely available laboratory tests on admission to the ED, including plasma sodium concentration.

METHODS

We retrospectively reviewed clinical and laboratory data of pediatric patients with AA who underwent emergency surgery at our department between January 2020 and December 2022. The patients were divided into two groups: histopathologically proven complicated AA (n = 80), and non-complicated AA (n = 155).

RESULTS

Complicated AA was associated with reduced plasma sodium and chloride concentrations (p < 0.001, both), decreased values of lymphocytes (p = 0.002), elevated C-reactive protein (CRP) ( p < 0.001), elevated values of white blood cells (WBC) and neutrophils (p = 0.012 and 0.001, respectively). In binomial logistic regression, increased levels of CRP and WBC, and decreased levels of sodium were predictors of complicated AA. The area under the ROC curve was 0.825 (95% CI 0.764, 0.886).

CONCLUSION

We identified mild hyponatremia and elevated CRP and WBC values as potential markers for distinguishing complicated from uncomplicated pediatric AA with implications for surgical approaches for treating complicated AA and conservative approaches for treating uncomplicated AA.

Lack of Routine Postoperative Labs Not Associated With Complications in Pediatric Perforated Appendicitis

INTRODUCTION

Postoperative (postop) management of pediatric perforated appendicitis varies significantly, and postop intra-abdominal abscesses (IAA) remain a significant issue. Between 2019 and 2020, our standardized protocol included routine postop labs after an appendectomy for perforated appendicitis. However, given the lack of predictive utility of these routine labs, we discontinued this practice in 2021. We hypothesize that discontinuing routine postop labs will not be associated with an increase in complication rates after an appendectomy for pediatric perforated appendicitis.

METHODS

A single-institution, retrospective review of all pediatric appendectomies for perforated appendicitis from January 2019 to December 2021 was conducted at University Hospitals Rainbow Babies and Children's Hospital in Cleveland, Ohio. Data were collected on rate of complications (IAA development, re-admissions, bowel obstructions, superficial surgical site infections, intensive care unit transfers, Clostridium difficile infections, allergic reactions, and transfusions), postop imaging, postop interventions, and length of stay. Statistical analysis was completed using Fisher's exact test and Mann-Whitney U-test.

RESULTS

A total of 109 patients (2019-2020 n = 61, 2021 n = 48) were included in the study. All 61 patients from 2019 to 2020 had postop labs compared to only eight patients in 2021. There was no statistically significant difference between the two groups in overall complication rates, but there was a decrease in IAAs reported in 2021 (P = 0.03). There were no statistically significant differences in other complications, postop imaging usage, or postop interventions. The median length of stay was 4.5 d in 2021 compared to 6.0 d in 2019-2020 (P = 0.009).

CONCLUSIONS

Discontinuing routine postop labs is not associated with an increase in overall complications rates. Further studies are needed to determine whether routine postop labs can be safely removed in pediatric patients with perforated appendicitis, which would reduce patient discomfort and care costs.

A prospective study to evaluate the contribution of the pediatric appendicitis score in the decision process

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).

Appendicitis in Children

The management of pediatric appendicitis continues to advance with the development of evidence-based treatment algorithms and a recent shift toward patient-centered treatment approaches. Further research should focus on development of standardized institution-specific diagnostic algorithms to minimize rates of missed diagnosis and appendiceal perforation and refinement of evidence-based clinical treatment pathways that reduce complication rates and minimize health care resource utilization.

Role of serum levels of tumour necrosis factor-like weak inducer of apoptosis (TWEAK) in predicting severity of acute appendicitis

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.

Labs Do Not Predict Postoperative Intra-abdominal Abscess in Pediatric Perforated Appendicitis

INTRODUCTION

We aim to evaluate the utility of postoperative labs in predicting the development of an intra-abdominal abscess (IAA) in pediatric patients with perforated appendicitis. We hypothesize that postoperative labs are not predictive of IAA development.

METHODS

This was a single-institution retrospective cohort study that included pediatric patients (n = 61) who underwent surgery for perforated appendicitis from January 1, 2019 to December 1, 2020. Patients were stratified into those who developed a postoperative IAA (n = 22) and those who did not (n = 39). Postoperative labs (white blood cell [WBC] count, absolute neutrophil count, platelet count, C-reactive protein) were examined. Mann-Whitney U tests and chi-square tests were used to assess for differences between groups.

RESULTS

There was extensive heterogeneity and overlap in postoperative lab values between patients who developed an IAA and those who did not. Almost all patients who developed an IAA had clinical signs that were indicative of abscess formation regardless of their postoperative WBC count or change in WBC count. While patients who developed an IAA had a higher postoperative median WBC count (10.8 versus 8.4, P = 0.003) and a smaller WBC count decrease (-4.9 versus -7.4, P = 0.01), no cutoff value for any of the examined lab values specifically predicted abscess formation. Postoperative median absolute neutrophil count (7.4 versus 4.0, P = 0.15), platelet count (360 versus 353, P = 0.98), and C-reactive protein (8.20 versus 5.32, P = 0.06) did not differ significantly.

CONCLUSIONS

We conclude that postoperative labs have limited clinical utility in evaluating IAA development in children with perforated appendicitis.

Diagnostic value of monocyte-lymphocyte ratio and red cell distribution width- lymphocyte ratio against other biomarkers in children with acute appendicitis, cross-sectional study

Our study aims to ascertain the diagnostic value of the Monocyte-lymphocyte ratio (MLR) and red cell distribution width (RDW)-lymphocyte ratio (RLR) by comparing them with other biomarkers in distinguishing patients with and without acute appendicitis (AA). A total of 223 children were recruited in the study conducted according to the Cross-Sectional Study design. Patients under 18 years were assigned to 3 groups; AA, nonspecific abdominal pain (NAP), and a control group. According to the outcome of our research, while C-reactive protein (CRP), white blood cell (WBC), neutrophil count (NEU), neutrophil to lymphocyte ratio (NLR), and MLR had excellent diagnostic power, RLR had acceptable diagnostic power, and platelet to lymphocyte ratio (PLR) had only fair diagnostic power. MLR and NLR, which are simple, inexpensive, and easily accessible parameters, can be recommended to be used together with other biomarkers in diagnosing AA in children.

Predictors and management outcomes of perforated appendicitis in sub-Saharan African countries: A retrospective cohort study

Background

Previous studies have found an association between various predictors and perforated appendicitis. However, there is limited evidence of studies determining the severity of acute appendicitis (AA) in resource-limited settings. Thus, this study aimed to identify predictors and outcomes of perforated appendicitis (PA) in sub-Saharan countries.

Methods

This is a retrospective cohort study of 298 adult patients who underwent surgical intervention for acute appendicitis. Demographic characteristics, clinical parameters, intraoperative findings, length of hospital stay, and postoperative complications were collected. We computed multivariate logistic regression to identify predictors of PA. P-value <0.05 was considered statistically significant.

Results

Of 298 patients, PA was 142(47.65%). The identified risk factors for PA are referred patients (AOR = 3.932; 95% CI (2.201–7.027), fever >38 °C (AOR = 4.569; 95% CI (2.249–9.282), and duration of symptoms >2 days (AOR = 2.704; 95% CI (1.400–5.222). Perforation was associated with an increased rate of postoperative complications (45.07vs. 6.41%; P < 0.001) and a longer length of hospital stay (3 vs. 5 days; P < 0.001).

Conclusions

The incidences of PA in our study are consistent with other reports in developing countries. Referred patients, longer duration of symptoms >2 days, and presence of fever >38 °C were the best predictors of PA. The overall total postoperative complications and the length of hospital stays were higher in PA. Based on our findings, we recommend that the identified predictors should be considered during the preoperative diagnosis and subsequent management.

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The rate of Perforated Appendix is relatively high in sub-Saharan countries.

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Duration of symptoms, fever and referred patients were the predictors of PA.

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PA increased the risk of postoperative morbidity and length of hospital stays.

Related Markers for the Precision Diagnosis of Complex Appendicitis in Children

Acute appendicitis is the most common surgical emergency in children. Despite the high incidence rate of appendicitis, it is sometimes misdiagnosed or missed. Complex appendicitis (CA) in children is characterized by a critical condition, several complications, and high mortality. Precision distinguishing between simple appendicitis and CA correctly is key to choosing appropriate treatment. A safe, cheap, rapid, extensive and accurate diagnostic marker of appendicitis will be of great significance for emergency general surgeons to treat suspected CA. Many studies have investigated possible diagnostic markers for the diagnosis of CA in children. In this study, studies related to CA in children in recent years are summarized, and the related markers and scoring system for the diagnosis of CA in children are summarized.

Refining sonographic criteria for paediatric appendicitis: combined effects of age-based appendiceal size and secondary findings

Objective

Appendiceal diameter is a primary sonographic determinant of paediatric appendicitis. We sought to determine if the diagnostic performance of outer appendiceal diameter differs based on age or with the addition of secondary sonographic findings.

Methods

We retrospectively reviewed patients aged less than 19 years who presented to the Boston Children’s Hospital ED and had an ultrasound (US) for the evaluation of appendicitis between November 2015 and October 2018. Our primary outcome was the presence of appendicitis. We analysed the cases to evaluate the optimal outer appendiceal diameter as a predictor for appendicitis stratified by age (<6, 6 to <11, 11 to <19 years), and with the addition of one or more secondary sonographic findings.

Results

Overall, 945 patients met criteria for inclusion, of which 43.9% had appendicitis. Overall, appendiceal diameter as a continuous measure demonstrated excellent test performance across all age groups (area under the curve (AUC) >0.95) but was most predictive of appendicitis in the youngest age group (AUC=0.99 (0.98–1.00)). Although there was no significant difference in optimal diameter threshold between age groups, both 7- and 8-mm thresholds were more predictive than 6 mm across all groups (p<0.001). The addition of individual (particularly appendicolith or echogenic fat) or combinations of secondary sonographic findings increased the diagnostic value for appendicitis above diameter alone.

Conclusions

Appendiceal diameter as a continuous measure was more predictive of appendicitis in the youngest group. Across all age groups, the optimal diameter threshold was 7 mm for the diagnosis of paediatric appendicitis. The addition of individual or combination secondary sonographic findings increases diagnostic performance.

Inflammatory parameters as predictive factors for complicated appendicitis: A retrospective cohort study

Introduction

Acute appendicitis is a major cause of acute abdomen. Although its diagnosis is clinical, it is often supported by complementary diagnostic tests. Sometimes, delay in diagnosis can lead to worsening of the clinical picture, resulting in a complicated acute appendicitis. Some series have studied some clinical and analytical parameters as possible predictors of complicated acute appendicitis.

Study design

A retrospective analysis of patients admitted for acute appendicitis and undergoing appendectomy between January 2014 and December 2017 was performed in order to assess the possible existence of preoperative analytical predictive factors for complicated acute appendicitis (such as leukocytosis, C-reactive protein and ratio between neutrophils and lymphocytes).

Results

841 patients underwent emergency appendectomy during the analysed period. This initial sample was divided into two groups: Group 1 with patients with uncomplicated acute appendicitis and Group 2 with patients with complicated acute appendicitis. Group 2's presentation age, duration of symptoms and hospital stay was significantly higher than Group 1. Regarding analytical parameters, the measurement of leukocytes, C-reactive protein and ratio between neutrophils and lymphocytes was significantly higher in patients with complicated acute appendicitis. After a multivariate analysis, it was found that only C-reactive protein was a good predictor of complicated acute appendicitis.

Conclusion

Several publications have studied and demonstrated the possible use of certain analytical parameters as predictors of complicated acute appendicitis. In our study, C-reactive protein proved to be a good independent predictor of complicated acute appendicitis and, therefore, when an assay of this protein exceeds 63.3 mg/L, faster surgical approach should be considered due to the high probability of the presence of a complicated picture of this clinical entity.

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Preoperative distinction of the severity of appendicitis can be challenging.

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Biochemical markers can help the surgeon to understand its severity and emergency.

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C-reactive protein shows to be a good predictor of complicated acute appendicitis.

Diagnostic accuracy of laboratory markers for diagnosis of acute appendicitis in children

BACKGROUND

Acute appendicitis (AA), the most common abdominal emergency disease, is one of the most important causes of hospitalization of children. Studies have shown that white blood cell (WBC) count, mean platelet volume (MPV), C‑reactive protein (CRP), and erythrocyte sedimentation rate (ESR) can play an important role in the diagnostic prediction of appendicitis. Therefore, the aim of this study was to evaluate the diagnostic value of WBC count, polymorphonuclear leukocytes (PMNs) percentage, MPV, CRP, and ESR for the diagnosis of AA.

METHODS

In this study, 100 medical records were reviewed for children referred to the hospital complaining of abdominal pain and who underwent operation with a provisional diagnosis of acute appendicitis based on clinical and laboratory findings. Patients were divided into two groups according to the pathology gold standard method: AA and the other group with acute abdominal pain without appendicitis (AAP). The diagnostic accuracy of WBC, PMNs%, MPV, ESR, and CRP were compared for patients with AA and AAP.

RESULTS

A total of 100 patients (50 with AA and 50 with AAP) were identified. The sensitivity and specificity of WBC and PMNs% were 78 and 66%, and 76 and 54%, respectively; ESR was 80 and 48%, respectively; and CRP was 82 and 62% (30-89%), respectively. A low specificity (8%) and 70% sensitivity was calculated using the cutoff point of 8.1 fl for MPV.

CONCLUSION

Our data suggest that children with AA often present with significantly higher WBC count, ESR level, CRP level, PMNs%, and lower MPV level. The results of the study showed that WBC, CRP, and ESR, along with other diagnostic methods, can be useful in diagnosing AA in children. MPV is not effective in the diagnosis of AA due to its specificity; however, a significantly lower level was found in children with AA.

The Diagnostic Value of Presepsin in Acute Appendicitis and Reference Ranges for Healthy Children

OBJECTIVE

This study aimed to investigate the diagnostic value of presepsin, a new inflammatory marker for paediatric appendicitis, and to determine a reference range of presepsin for children.

METHODS

This single-center prospective study was conducted in our paediatric emergency department between 1 February 2021 and 1 July 2021. Patients aged 0-18 years diagnosed with acute appendicitis, which was pathologically confirmed, and healthy volunteers in the same age group were included in the study. Serum presepsin levels were analysed using an enzyme-linked immunosorbent assay reader. In addition to presepsin, other acute-phase reactants, paediatric appendicitis scores and imaging methods were evaluated.

RESULTS

There were 94 patients in the acute appendicitis group and 102 healthy volunteers in the control group. Median values were compared between the two groups, and no statistically significant differences were found (p = 0.544). In addition, no statistically signivficant differences in presepsin levels were found between the acute and perforated appendicitis groups (p = 0.344). The median (IQ1-IQ3) reference range for presepsin in healthy children was 0.9950 (0.7575-1.610) ng/mL.

CONCLUSION

Presepsin is not a suitable marker for the diagnosis of acute appendicitis. We observed that serum presepsin levels were not elevated in paediatric appendicitis, which is a local infection, in contrast to previous studies.

Predictive Value of Red Blood Cell Distribution Width, Mean Platelet Volume and Platelet Distribution Width in Children with Acute Appendicitis

Background and Objectives: Acute appendicitis in pediatric patients is one of the most common surgical emergencies, but the early diagnosis still remains challenging. The aim of this study was to determine the predictive value of Red blood cell distribution width (RDW), Mean platelet volume (MPV) and Platelet distribution width (PDW) in children with acute appendicitis. Materials and Methods: This study was a retrospective assessment of laboratory findings (RDW, MPV, PDW) of patients who underwent surgical treatment for acute appendicitis from January 2019 to December 2020. Result: During this period, 223 appendectomies were performed at our Institute. In 107 (43%) cases appendicitis was uncomplicated, while in 116 (46.6%) it was complicated. WBC and RDW/MPV ratio were significant parameters for the diagnosis of acute appendicitis with cut-off values of 12.86 (susceptibility: 66.3%; specificity: 73.2%) and 1.64 (susceptibility: 59.8%; specificity: 71.9%), respectively. WBC and RDW/RBC ratio were independent variables for the diagnosis of complicated appendicitis. The cut-off values were 15.05 for WBC (sensitivity: 60.5%; specificity: 70.7%) and 2.5 for RDW/RBC ratio (sensitivity: 72%; specificity: 52.8%). Conclusions: WBC is an important predictor of appendicitis and complicated appendicitis. RDW, MPV and PDW alone have no diagnostic value in pediatric acute appendicitis or predicting the degree of appendix inflammation. However, the RDW/MPV ratio can be an important predictor of appendix inflammation, with higher values in patients with more severe appendix inflammation. RDW/RBC ratio may be an important predictor of complicated appendicitis.

Novel molecular biomarkers and diagnosis of acute appendicitis in children

Reliable and efficient diagnosis of pediatric appendicitis is essential for the establishment of a clinical management plan and improvement of patient outcomes. Current strategies used to diagnose a child presenting with a suspected appendicitis include laboratory studies, clinical scores and diagnostic imaging. Although these modalities work in conjunction with each other, one optimal diagnostic strategy has yet to be agreed upon. The recent introduction of precision medicine techniques such as genomics, transcriptomics, proteomics and metabolomics has increased both the diagnostic sensitivity and specificity of appendicitis. Using these novel strategies, the integration of precision medicine into clinical practice via point-of-care technologies is a plausible future. These technologies would assist in the screening, diagnosis and prognosis of pediatric appendicitis.

Utility of biomarkers in predicting complicated appendicitis: can immature granulocyte percentage and C-reactive protein be used?

BACKGROUND

Acute appendicitis is the most common reason for abdominal surgery in children. The aim of this study was to evaluate the utility of biomarkers in predicting complicated appendicitis (CA).

METHODS

Patients having a diagnosis of acute appendicitis who underwent operations were retrospectively determined, and the utility of biomarkers in predicting CA was evaluated.

RESULTS

A total of 251 patients were included in the study. The mean age was 130.9 ± 48.8 months, 148 of the cases (59%) were simple appendicitis, and 103 (41%) were CA. The C-reactive protein (CRP) levels, immature granulocyte (IG) percentage, white blood cell counts, and absolute neutrophil counts were significantly higher in the CA patients. The bilirubin levels and neutrophil to lymphocyte ratios were not useful for predicting CA. The best area under the curve (AUC) values to predict CA were with the IG percentage and CRP level (0.82), the IG percentage [odds ratio (OR) 9.36, 95% CI (4.94-17.75), p < 0.001] and CRP [OR 8.42, 95% CI (4.72-15.02), p < 0.001] were the best marker in predicting CA. The sensitivity of the IG percentage and CRP level were higher than other markers.

CONCLUSION

To predict CA, the best AUC values were associated with the IG percentage and the CRP level. Because it is easy, fast to measure, does not require taking extra blood, and does not lead to additional costs, IG percentage may be preferred in the diagnosis of patients with CA.

Levels of C-Reactive Protein and Sodium May Differentiate a Perforated Appendix from a Nonperforated Appendix in Children

Background

Acute appendicitis (AA) might be amenable to conservative antibiotic treatment, whereas a perforated appendix (PA) necessitates surgery. We investigated the value of clinical–laboratory markers in distinguishing AA from a PA.

Methods

Retrospectively obtained preoperative parameters for 306 consecutive patients (<18 years) with histologically confirmed appendicitis (AA (n = 237) vs. PA (n = 69)), treated at our institution between January 2014 and December 2017.

Results

A PA was associated with male preponderance, younger age, decreased sodium level and increased white blood cell count, Tzanakis score, C-reactive protein (CRP) level, and CRP-to-lymphocyte ratio (CLR). Upon discrimination analysis, CLR and CRP displayed the highest accuracy in differentiating a PA from AA. Regression analysis identified levels of CRP, sodium, and the Tzanakis score as independent predictors for a PA.

Conclusion

Levels of CLR, CRP, sodium, and Tzanakis score might support decision-making regarding treatment options for pediatric appendicitis.

sTREM-1 as a diagnostic biomarker for acute appendicitis in children

BACKGROUND

The typical history of acute appendicitis is observed in less than 60% of cases. Therefore, searching for a surrogate marker is mandatory. Our goal was to determine whether the soluble triggering receptor expressed on myeloid cells (sTREM-1) is an efficient biomarker for acute appendicitis.

METHODS

sTREM-1 serum levels were measured in addition to carrying out routine diagnostic tests (urine dipstick, complete blood count and CRP) in children admitted to the Emergency Department with suspected appendicitis. Statistical analysis was performed in order to examine whether sTREM-1 was a significant predictor of appendicitis.

RESULTS

Fifty three of 134 children enrolled in the study were diagnosed with appendicitis. There was no significant difference in serum sTREM-1 levels (p = 0.111) between children with or without appendicitis (n = 81). Leukocytes, neutrophils and CRP were significantly elevated in the appendicitis group (p < 0.001). The appendix diameter was significantly larger and the Alvarado score significantly higher in the appendicitis group (p < 0.001).

CONCLUSION

serum sTREM-1 is not a good marker for acute appendicitis. Customary tests in addition to a proper patient history and physical examination are still the most effective methods to diagnose acute appendicitis.

Serum Soluble CD40 Ligand in Predicting Simple Appendicitis and Complicated Appendicitis at Different Time Points in Children

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.

Making a Decision between Acute Appendicitis and Acute Gastroenteritis

Acute appendicitis is one of the most common pediatric abdominal emergencies. Early diagnosis is vital for a positive outcome. However, it may initially present with diarrhea and vomiting, mimicking acute gastroenteritis, thus delaying prompt surgery. Differentiating appendicitis from gastroenteritis in a timely manner poses a challenge. Therefore, we aim to investigate the predictors that help distinguish acute appendicitis from acute gastroenteritis. We conducted a retrospective case-control study, evaluating children admitted due to abdominal pain with diarrhea. Subjects were divided into two groups according to the final diagnoses: acute appendicitis and acute gastroenteritis. We adopted multiple logistic regression analysis and the area under the receiver operating characteristic curve to identify independent predictors of acute appendicitis and select the best model. A total of 32 patients diagnosed with appendicitis and 82 patients with gastroenteritis were enrolled. Five independent predictors of acute appendicitis included vomiting, right lower quadrant (RLQ) pain, stool occult blood (OB), white blood cell (WBC) count, and C-reactive protein (CRP). The revised combined model exhibited a higher degree of discrimination and outperformed the pediatric appendicitis score (PAS) model. In conclusion, our study was proved to be helpful for assessing cases with abdominal pain and diarrhea in order to more accurately distinguish appendicitis from gastroenteritis in children in a timely manner.

sB7H3 in Children with Acute Appendicitis: Its Diagnostic Value and Association with Histological Findings

Background

Several efforts have been made to find out a valuable marker to assist the diagnosis and differentiation of gangrenous/perforated appendicitis. We aimed to determine the diagnostic capacity of soluble B7H3 (sB7H3) in acute appendicitis (AA) and its accuracy as a predictor of the severity of appendicitis.

Methods

182 children were allocated into four groups as follows: control group (CG, 90), simple appendicitis (SA, 12), purulent appendicitis (PA, 49), and gangrenous appendicitis (GA, 31). Prior to appendectomy, blood was collected and sent for analysis of routine examination and cytokines (sB7H3 and TNF-α). We compared values of all measured parameters according to histological findings. Furthermore, we assigned AA patients into the nonperforated appendicitis group and the perforated appendicitis group. The diagnostic effects of significant markers were assessed by ROC curves.

Results

Only the levels of CRP, FIB, and sB7H3 had a remarkable rising trend in AA-based groups, while differences in the levels of CRP and FIB between simple appendicitis and purulent appendicitis were not statistically significant. In addition, sB7H3 was found as the only marker in children with AA, which was markedly associated with the degree of histological findings of the appendix. Furthermore, sB7H3 had a high diagnostic value in predicting AA and complex appendicitis (PA+GA) in children. However, the diagnostic performance of sB7H3 for distinguishing PA from GA was not remarkable. Additionally, only the levels of CRP and sB7H3 were statistically different between the nonperforated appendicitis group and the perforated appendicitis group. The diagnostic performance of CRP and sB7H3 could not merely predict perforation of AA in children; however, the diagnostic performance was improved after combination.

Conclusions

sB7H3 could be used as a valuable marker to predict the presence of AA and complex AA in children. However, the diagnostic value of sB7H3 to predict gangrenous/perforated appendicitis was not found to be remarkable. The combination of sB7H3 and CRP might improve the prediction of perforated appendicitis.

A Study on the Clinical Factors Associated with Acute Appendicitis and Perforated Appendicitis among Children in a Secondary Medical Centre in Malaysia

Background

Appendicitis complicated with appendiceal perforation is common among children. The delay in diagnosis of appendicitis is due to children’s varied presentations and their difficulty in communicating symptoms. We aimed to identify clinical factors that aid in predicting acute appendicitis (AA) and perforated appendicitis (PA) among children.

Methods

This retrospective study involved 215 children aged 12 years and below with the initial diagnosis of AA and PA. Clinical factors studied were demographics, presenting symptoms, body temperature on admission (BTOA), white cell count (WCC), absolute neutrophil count (ANC), platelet count and urinalysis. Simple and multiple logistic regressions were used to determine the odds ratio of the statistically significant clinical factors. Results: The mean age of the included children was 7.98 ± 2.37 years. The odds of AA increased by 2.177 times when the age was ≥ 8 years (P = 0.022), 2.380 times when duration of symptoms ≥ 2 days (P = 0.011), 2.447 times with right iliac fossa (RIF) pain (P = 0.007), 2.268 times when BTOA ≥ 38 °C (P = 0.020) and 2.382 times when neutrophil percentage was ≥ 76% (P = 0.045). It decreased by 0.409 times with non-RIF pain (P = 0.007). The odds of PA was increased by 4.672 times when duration of symptoms ≥ 2 days (P = 0.005), 3.611 times when BTOA ≥ 38 °C (P = 0.015) and 3.678 times when neutrophil percentage ≥ 76% (P = 0.016). There was no significant correlation between WCC and ANC with AA and PA.

Conclusion

Older children with longer duration of symptoms, RIF pain and higher BTOA are more likely to have appendicitis. The risk of appendiceal perforation increases with longer duration of symptoms and higher BTOA.

New Oxidative Stress Markers Useful in the Diagnosis of Acute Appendicitis in Children: Thiol/Disulfide Homeostasis and the Asymmetric Dimethylarginine Level

OBJECTIVES

The aim of this study was to evaluate 2 new oxidative stress markers, thiol/disulfide homeostasis status and the asymmetric dimethylarginine (ADMA) level, in children with acute appendicitis (AA) and to evaluate their diagnostic utility.

METHODS

This case-control study included 45 patients with AA and 35 healthy children. Age, sex, white blood cell count, neutrophil-to-lymphocyte ratio, high-sensitivity C-reactive protein (hs-CRP) level, ultrasonographic findings, thiol/disulfide homeostasis parameters (native and total thiol levels, native thiol/total thiol ratios [antioxidant parameters], and disulfide, disulfide/native thiol, and disulfide/total thiol ratios [oxidant parameters]), and the ADMA level were compared between the 2 groups.

RESULTS

The native and total thiol levels, and the native thiol/total thiol ratio, were significantly lower, and the disulfide level and disulfide/native thiol and disulfide/total thiol ratios significantly higher, in the AA compared with the control group (all P < 0.001). The ADMA level was significantly higher in a perforated versus nonperforated subgroup of AA patients, but the thiol/disulfide homeostasis parameters did not differ significantly between the two subgroups. In addition, the hs-CRP level and appendiceal wall thickness were higher in the perforated subgroup. The thiol/disulfide antioxidant parameters and ADMA level correlated negatively with the white blood cell count, the neutrophil-to-lymphocyte ratio, and the hs-CRP level, in the AA group, but correlated positively with oxidant parameters. The sensitivity and specificity of the disulfide/native thiol and disulfide/total thiol ratios were high when used to diagnose AA, whereas the sensitivity of the ADMA level was high when used to diagnose perforated appendicitis.

CONCLUSIONS

Thiol/disulfide homeostasis and the ADMA level, together with certain other parameters, may be useful biomarkers of AA in children.

Determination of pentraxin 3 levels in diagnosis of appendicitis in children

BACKGROUND

The aim of this study is to determine whether pentraxin 3 (PTX3) levels can be used in the diagnosis of appendicitis in children.

METHODS

Fifteen children under 18 years old, who gave blood samples for reasons other than inflammatory conditions, and 40 children who were proved to have appendicitis (non-perforated or perforated) between August 2017 and January 2018, were enrolled in the study. Patients were classified into subgroups: group 1 (healthy children without any sign of inflammation, n = 15), group 2 (non-perforated appendicitis, n = 25), and group 3 (perforated appendicitis, n = 15).

RESULTS

The median PTX3 value was 1.01 ng/mL (minimum value: 0.82, maximum: 1.28) in the control group. The median PTX3 values prior to surgery were 20.68 ng/mL (minimum: 1.02, maximum: 28.471) and 1.46 (minimum: 1.05, maximum: 23.421) ng/mL for non-perforated appendicitis and perforated appendicitis respectively. The PTX3 levels were significantly higher in groups 2 and 3 than in group 1 (P < 0.01). According to receiver operating characteristics analysis the cut-off value of PTX3 levels at admission for appendicitis was 1.30 ng/mL with a sensitivity of 75% and a specificity of 100% (area under the curve, 0.939; P = 0.000).

CONCLUSIONS

Pentraxin 3 levels were significantly higher in children with appendicitis than in healthy children. Children with high PTX3 levels complaining of right lower quadrant pain may support a diagnosis of appendicitis. Future studies should be conducted to evaluate changes in PTX3 levels by comparing children with appendicitis versus acute abdominal pain in larger populations to further determine the value of PTX3 in the diagnosis of appendicitis in children.

Perforation in pediatric non-complicated appendicitis treated by antibiotics: the real incidence

PURPOSE

The incidence of perforation during antibiotic therapy (AT) of children triaged as non-complicated acute appendicitis (NC-Ap) was investigated.

METHODS

Abdominal ultrasonography (US) and/or computed tomography (CT) scans from cases of perforation identified at appendectomy for failed AT were reassessed blindly by a panel of board-certified specialists for any evidence of pre-AT morbidity suggestive of perforation.

RESULTS

Of 521 cases triaged as NC-Ap, symptoms resolved with AT in 452 cases (86.8%). All 69/521 (13.2%) cases with persistent symptoms had urgent appendectomy, and 12/521 (2.3%) were found to have perforated. Blind reassessment of US and/or CT scans from these cases identified seven with evidence of perforation when they were triaged as NC-Ap. Thus, the actual incidence of perforation during AT for NC-Ap was actually 12-7 = 5/521 (0.95%).

CONCLUSIONS

Perforation is generally believed to be a complication of AT, but inappropriate triaging of cases for AT can bias results by artificially inflating the number of perforations, in this study, by more than double. We are the first to assess the unbiased incidence of perforation during AT for NC-Ap, by reassessing pre-AT US and/or CT scans. The incidence of perforation during AT is actually negligible.

A novel nomogram for the differential diagnosis between advanced and early appendicitis in pediatric patients

Aim: To develop a nomogram for differential diagnosis between advanced and early pediatric appendicitis (PA). Patients & methods: We retrospectively studied 669 PA patients. Patient characteristics and 24 serum markers were subjected to univariate and multivariate analysis, based on which the nomogram was constructed. Results: Fibrin degradation product, CRP and Na⁺ differed significantly between the advanced and early PA. The value of area under the receiver operating characteristic curve (AUC) was 0.8602, which was greater than that of a single serum marker. Furthermore, the nomogram showed better discriminative ability than the biomarker alone. Notably, validation indicated high stability and reproducibility. Conclusion: The nomogram is superior to the serum marker alone, and may hold promise in clinical application.

Laboratory Markers in the Prediction of Acute Perforated Appendicitis in Children

Objective

This study aimed to explore the laboratory markers associated with perforation in children with acute appendicitis.

Methods

This retrospective study reviewed 1895 children (3–18 years old) with confirmed acute appendicitis from 2007 to 2017. Clinical (demographic characteristics, symptoms, and signs) and laboratory data (white blood cell count, C-reactive protein (CRP), procalcitonin, D-lactate, platelet count, bilirubin, aspartate aminotransferase, and alanine aminotransferase) were collected and compared between perforated and nonperforated groups. The logistic regression analysis was performed to identify independent risk factors.

Results

Of all patients, 613 children were perforated. Children with perforation had significantly longer duration of symptoms, higher white blood cell count, CRP level, and neutrophils percentage, and lower serum sodium level. Elevated white blood cell count with CRP level and elevated neutrophils percentage with CRP level were found to be associated with risk of perforation.

Conclusions

White blood cell count with C-reactive protein and neutrophils percentage with CRP are important markers in distinguishing perforated appendicitis from nonperforated appendicitis in pediatric subjects.

Diagnostic accuracy of procalcitonin for overall and complicated acute appendicitis in children: a meta-analysis

Background

Diagnostic value of procalcitonin (PCT) for acute appendicitis (AA) has been evaluated in adult patients, but the application in children remains controversial. The aim of this study was to evaluate the diagnostic value of PCT for overall and complicated AA in children.

Methods

The PubMed, EMBASE, Web of Science, Cochrane Database of Systematic Reviews, Chinese National Knowledge Infrastructure, and Wanfang were searched along with reference lists of relevant articles up to January 2018 without language restrictions. Original articles that reported the performance of PCT in the diagnosis of pediatric AA and associated complications were selected. To assess the diagnostic value of PCT, sensitivity, specificity, diagnostic odds ratios (DORs), summary receiver operating characteristic (ROC) curves, area under the curve (AUC), and 95% confidence intervals (95% CIs) were estimated.

Results

Seven qualifying studies (504 confirmed AA and 368 controls) from 6 countries for overall AA and 4 studies (187 complicated AA and 185 uncomplicated AA) for complicated AA from 3 countries were identified. The pooled sensitivity and specificity of PCT for the diagnosis of pediatric AA were 0.62 (95% CI: 0.57–0.66) and 0.86 (95% CI: 0.82–0.89), respectively. The DOR was 21.4 (95% CI: 3.64–126.1) and the AUC was 0.955. PCT was more accurate in diagnosing complicated appendicitis, with a pooled sensitivity of 0.89 (95% CI: 0.84–0.93), specificity of 0.90 (95% CI: 0.86–0.94), and DOR of 76.73 (95% CI: 21.6–272.9).

Conclusion

This meta-analysis showed that PCT may have potential value in diagnosing pediatric AA. Moreover, PCT had greater diagnostic value in identifying pediatric complicated appendicitis.

Acute eosinophilic appendicitis simulating uncomplicated appendicitis

Acute appendicitis is one of the most common abdominal emergencies worldwide. Uncomplicated appendicitis (UA), which does not involve perforation or peritonitis, has recently been treated with antibiotic therapy. Here, we report a case of acute eosinophilic appendicitis (AEA) that simulated UA and did not respond to antibiotic therapy. A 20-year-old Japanese woman emergently presented with the chief complaint of pain at the right iliac fossa. CT showed only swelling of the appendix. She was diagnosed with UA, and she received antibiotic therapy initially. However, the treatment was not effective and appendectomy was performed. The final histopathological diagnosis was AEA. The findings of this case suggest that AEA is likely to be diagnosed as UA. As AEA can simulate UA, the possibility of AEA should be considered when antibiotic therapy is not effective.

Perforation risk in pediatric appendicitis: assessment and management

Perforated appendicitis, as defined by a visible hole in the appendix or an appendicolith free within the abdomen, carries significant morbidity in the pediatric population. Accurate diagnosis is challenging as there is no single symptom or sign that accurately predicts perforated appendicitis. Younger patients and those with increased duration of symptoms are at higher risk of perforated appendicitis. Elevated leukocytosis, bandemia, high C-reactive protein, hyponatremia, ultrasound, and CT are all useful tools in diagnosis. Distinguishing patients with perforation from those without is important given the influence of a perforation diagnosis on the management of the patient. Treatment for perforated appendicitis remains controversial as several options exist, each with its indications and merits, illustrating the complexity of this disease process. Patients may be managed non-operatively with antibiotics, with or without interval appendectomy. Patients may also undergo appendectomy early in the course of their index hospitalization. Factors known to predict failure of non-operative management include appendicolith, leukocytosis greater than 15,000 white blood cells per microliter, increased bands, and CT evidence of disease beyond the right lower quadrant. In this review, the indications and benefits of each treatment strategy will be discussed and an algorithm to guide treatment decisions will be proposed.

Assessment of proadrenomedullin as diagnostic or prognostic biomarker of acute appendicitis in children with acute abdominal pain

BACKGROUND

Acute appendicitis (AA) is one of the most frequent surgical pathologies in pediatrics.

OBJECTIVES

To investigate the utility of proadrenomedullin (pro-ADM) for the diagnosis of AA.

METHODS

Prospective, analytical, observational, and multicenter study conducted in 6 pediatric emergency departments. Children up to 18 years of age with suspected AA were included. Clinical, epidemiological, and analytical data were collected.

RESULTS

We studied 285 children with an average age of 9.5 years (95% confidence interval [CI], 9.1-9.9). AA was diagnosed in 103 children (36.1%), with complications in 10 of them (9.7%). The mean concentration of pro-ADM (nmol/L) was higher in children with AA (0.51 nmol/L, SD 0.16) than in children with acute abdominal pain (AAP) of another etiology (0.44 nmol/L, SD 0.14; p < 0.001). This difference was greater in complicated cases compared with uncomplicated AA (0.64 nmol/L, SD 0.17 and 0.50 nmol/L, SD 0.15, respectively; p = 0.005). The areas under the receiver-operating characteristic curves were 0.66 (95% CI, 0.59-0.72) for pro-ADM, 0.70 (95% CI, 0.63-0.76) for C-reactive protein (CRP), 0.84 (95% CI, 0.79-0.89) for neutrophils, and 0.84 (95% CI, 0.79-0.89) for total leukocytes. The most reliable combination to rule out AA was CRP ≤1.25 mg/dL and pro-ADM ≤0.35 nmol/L with a sensitivity of 96% and a negative predictive value of 93%.

CONCLUSION

Children with AA presented higher pro-ADM values than children with AAP of other etiologies, especially in cases of complicated AA. The combination of low values of pro-ADM and CRP can help to select children with low risk of AA.

Metabolomic and inflammatory mediator based biomarker profiling as a potential novel method to aid pediatric appendicitis identification

Various limitations hinder the timely and accurate diagnosis of appendicitis in pediatric patients. The present study aims to investigate the potential of metabolomics and cytokine profiling for improving the diagnosis of pediatric appendicitis. Serum and plasma samples were collected from pediatric patients for metabolic and inflammatory mediator analyses respectively. Targeted metabolic profiling was performed using Proton Nuclear Magnetic Resonance Spectroscopy and Flow Injection Analysis Mass Spectrometry/Mass Spectrometry and targeted cytokine/chemokine profiling was completed using a multiplex platform to compare children with and without appendicitis. Twenty-three children with appendicitis and 35 control children without appendicitis from the Alberta Sepsis Network pediatric cohorts were included. Metabolomic profiling revealed clear separation between the two groups with very good sensitivity (80%), specificity (97%), and AUROC (0.93 ± 0.05) values. Inflammatory mediator analysis also distinguished the two groups with high sensitivity (82%), specificity (100%), and AUROC (0.97 ± 0.02) values. A biopattern comprised of 9 metabolites and 7 inflammatory compounds was detected to be significant for the separation between appendicitis and control groups. Integration of these 16 significant compounds resulted in a combined metabolic and cytokine profile that also demonstrated strong separation between the two groups with 81% sensitivity, 100% specificity and AUROC value of 0.96 ± 0.03. The study demonstrated that metabolomics and cytokine mediator profiling is capable of distinguishing children with appendicitis from those without. These results suggest a potential new approach for improving the identification of appendicitis in children.

The Use of Metabolomics and Inflammatory Mediator Profiling Provides a Novel Approach to Identifying Pediatric Appendicitis in the Emergency Department

Multiplexed profiling approaches including various ‘omics’ platforms are becoming a new standard of biomarker development for disease diagnosis and prognosis. The present study applied an integrated metabolomics and cytokine profiling approach as a potential aid to the identification of pediatric appendicitis. Metabolic analysis using serum (n = 121) and urine (n = 102) samples, and cytokine analysis using plasma (n = 121) samples from children presenting to the Emergency Department with abdominal pain were performed. Comparisons between children with appendicitis vs. non-appendicitis abdominal pain, and with perforated vs. non-perforated appendicitis were made using multivariate statistics. Serum and urine biomarker patterns were statistically significantly different between groups. The combined serum metabolomics and inflammatory mediator model revealed clear separation between appendicitis and non-appendicitis abdominal pain (AUROC: 0.92 ± 0.03) as well as for perforated and non-perforated appendicitis (AUROC: 0.88 ± 0.05). Urine metabolic analysis also demonstrated distinction between the groups appendicitis and non-appendicitis abdominal pain (AUROC: 0.85 ± 0.04), and perforated and non-perforated appendicitis (AUROC: 0.98 ± 0.02). In children presenting to the Emergency Department with abdominal pain, metabolomics and inflammatory mediator profiling are capable of distinguishing children with appendicitis from those without. The approach also differentiates between severities of disease. These results provide an important first step towards a potential aid for improving appendicitis identification.

Biomarkers to estimate the probability of complicated appendicitis

BACKGROUND

The conventional paradigm that all children with appendicitis require an appendectomy is being challenged by the idea that some patients may be successfully managed non-operatively. The study aimed to determine if matrix metalloproteinases (MMPs) and tissue inhibitors of metalloproteinase (TIMPs) are candidate biomarkers for estimating the probability of complicated appendicitis in pediatric patients.

METHODS

The study was a single-institution, prospective cohort study. MMP and TIMP serum protein concentrations were measured in patients with suspected appendicitis. Three hundred and thirty-one patients were enrolled with appendicitis. Classification and Regression Tree (CART) analysis was used to determine the combination of candidate biomarkers that best predicted complicated appendicitis.

RESULTS

The CART-generated decision tree for the derivation cohort included WBC count, MMP-8, MMP-9, MMP-12, TIMP-2, and TIMP-4 and had the following test characteristics for estimating the probability of complicated appendicitis (95% CI): AUC 0.86 (0.81-0.90); sensitivity 91% (83-96); specificity 61% (53-68); positive predictive value 58% (50-66); negative predictive value 92% (84-96); positive likelihood ratio (LR) 2.3 (1.9-2.8); and negative LR 0.15 (0.08-0.3).

CONCLUSIONS

MMPs and TIMPs have the potential to serve as biomarkers to estimate the probability of complicated appendicitis in pediatric patients. The multi-biomarker-based decision tree has test characteristics suggesting clinical utility for decision making.

LEVEL OF EVIDENCE

Level II: Study of Diagnostic Test.

A pre-operative clinical scoring system to distinguish perforation risk with pediatric appendicitis

IMPORTANCE

Appendicitis is a common, potentially serious pediatric disease. An important factor in determining management strategy [whether/when to perform appendectomy, duration of antibiotic therapy/hospitalization, etc.] and predicting outcome is distinguishing whether perforation is present.

OBJECTIVE

The objective was to determine efficacy of commonly assessed pre-operative variables in stratifying perforation risk in children with appendicitis.

DESIGN

A retrospective analysis of consecutive cases was performed.

SETTING

The setting was a large urban hospital pediatric emergency department.

PARTICIPANTS

Four hundred forty-eight consecutive cases of CT [computerized tomography]-confirmed pediatric appendicitis during a 6-year period in an urban pediatric ED [emergency department]: 162 with perforation and 286 non-perforated.

MAIN OUTCOME(S) AND MEASURE(S)

To determine efficacy of clinical and laboratory variables with distinguishing perforation outcome in children with appendicitis.

RESULTS

Regression analysis identified 3 independently significant variables associated with perforation outcome - and determined their ideal threshold values: duration of symptoms>1day; ED-measured fever [body temperature >38.0 °C]; CBC WBC absolute neutrophil count >13,000/mm³. The resulting multivariate ROC [receiver operating characteristic] curve after applying these threshold values gave an AUC [area under curve] of 89% for perforation outcome [p<0.001]. Risk for perforation was additive with each additional predictive variable exceeding its threshold value, linearly increasing from 7% with no variable present to 85% when all 3 variables are present.

CONCLUSIONS

A pre-operative scoring system comprised of 3 commonly assessed clinical/laboratory variables is useful in stratifying perforation risk in children with appendicitis. Physicians can utilize these factors to gauge pre-operative risk for perforation in children with appendicitis, which can potentially aid in planning subsequent management strategy.

LEVEL OF EVIDENCE

III.

The diagnostic value of hepcidin to predict the presence and severity of appendicitis in children

BACKGROUND

The aim of this study was to determine the diagnostic capacity of hepcidin in pediatric acute appendicitis and its accuracy as a predictor of the severity of appendicitis.

MATERIALS AND METHODS

In children with appendicitis (n = 39), leukocytes, platelet count, and the serum levels of C-reactive protein (CRP) and hepcidin were compared to a control group (n = 25) of patients with unspecific abdominal pain. Additionally, parameters were compared between children with simple (n = 17) and complicated appendicitis (n = 22). Receiver operation characteristic analyses of the different parameters were performed and the areas under the curve (AUCs) calculated.

RESULTS

Leukocytes and serum hepcidin levels were significantly higher in children with acute appendicitis versus control group (13.7 ± 5.7 versus 9.8 ± 3.9 G/L, P = 0.005 and 31.3 ± 21.7 versus 20.4 ± 14 ng/mL, P = 0.039). AUCs for hepcidin, leukocytes, and CRP were 0.654, 0.711, and 0.619, respectively. Complicated appendicitis was associated with significantly higher hepcidin concentrations compared to simple appendicitis (38.5 ± 17.6 ng/mL versus 21.6 ± 23.4 ng/mL, P < 0.001). A combination of leukocytes, CRP, and hepcidin had the highest AUC (0.914) to predict complicated appendicitis.

CONCLUSIONS

Increased serum levels of hepcidin were found in children with appendicitis compared to controls. While hepcidin was useful to identify patients with complicated appendicitis as it does not seem appropriate to distinguish between simple appendicitis and other causes for acute abdominal pain.

The Heidelberg Appendicitis Score Predicts Perforated Appendicitis in Children

BACKGROUND

In the future, surgical management of pediatric appendicitis might become limited to nonperforating appendicitis. Thus, it becomes increasingly important to differentiate advanced from simple appendicitis and to predict perforated appendicitis among a group of children with right-sided abdominal pain, which was the aim of this study.

METHODS

An institutionally approved, single-center retrospective analysis of all patients with appendectomy from January 2009 to December 2010 was conducted. All diagnostic aspects were evaluated to identify predictors and differentiators of perforated appendicitis.

RESULTS

In 2 years, 157 children suffered from appendicitis. Perforation occurred in 47 (29.9%) of the patients. C-reactive protein (CRP) levels higher than 20 mg/dL ( P = .037) and free abdominal fluid on ultrasonography ( P = .031) are the most important features to differentiate perforated from simple appendicitis. Moreover, all children with perforation had a positive Heidelberg Appendicitis Score (HAS). A negative HAS excludes perforation in all cases (negative predictive value = 100%).

DISCUSSION

Perforated appendicitis can be ruled out by the HAS. In a cohort with right-sided abdominal pain, perforation should be considered in children with high CRP levels and free fluids or abscess formation on ultrasound.

Can common serum biomarkers predict complicated appendicitis in children?

PURPOSE

As appendicitis in children can be managed differently according to the severity of the disease, we investigated whether commonly used serum biomarkers on admission could distinguish between simple and complicated appendicitis.

METHODS

Admission white blood cell (WBC), neutrophil (NEU), and C-reactive protein (CRP) levels were analysed by ROC curve, and Kruskal-Wallis and contingency tests. Patients were divided according to age and histology [normal appendix (NA), simple appendicitis (SA), complicated appendicitis (CA)].

RESULTS

Of 1197 children (NA = 186, SA = 685, CA = 326), 7% were <5 years, 55% 5-12, 38% 13-17. CA patients had higher CRP and WBC levels than NA and SA (p < 0.0001). NEU levels were lower in NA compared to SA or CA (p < 0.0001), but were similar between SA and CA (p = 0.6). CA patients had higher CRP and WBC levels than SA patients in 5-12- (p < 0.0001) and 13-17-year groups (p = 0.0075, p = 0.005), but not in <5-year group (p = 0.72, p = 0.81). We found CRP >40 mg/L in 58% CA and 37% SA (p < 0.0001), and WBC >15 × 10⁹/L in 58% CA and 43% SA (p < 0.0001).

CONCLUSIONS

Admission CRP and WBC levels may help the clinician predict complicated appendicitis in children older than 5 years of age. Early distinction of appendicitis severity using these tests may guide caregivers in the preoperative decision-making process.

Diagnostic Accuracy of History, Physical Examination, Laboratory Tests, and Point-of-care Ultrasound for Pediatric Acute Appendicitis in the Emergency Department: A Systematic Review and Meta-analysis

BACKGROUND

Acute appendicitis (AA) is the most common surgical emergency in children. Accurate and timely diagnosis is crucial but challenging due to atypical presentations and the inherent difficulty of obtaining a reliable history and physical examination in younger children.

OBJECTIVES

The aim of this study was to determine the utility of history, physical examination, laboratory tests, Pediatric Appendicitis Score (PAS) and Emergency Department Point-of-Care Ultrasound (ED-POCUS) in the diagnosis of AA in ED pediatric patients. We performed a systematic review and meta-analysis and used a test-treatment threshold model to identify diagnostic findings that could rule in/out AA and obviate the need for further imaging studies, specifically computed tomography (CT) scan, magnetic resonance imaging (MRI), and radiology department ultrasound (RUS).

METHODS

We searched PubMed, EMBASE, and SCOPUS up to October 2016 for studies on ED pediatric patients with abdominal pain. Quality Assessment Tool for Diagnostic Accuracy Studies (QUADAS-2) was used to evaluate the quality and applicability of included studies. Positive and negative likelihood ratios (LR+ and LR-) for diagnostic modalities were calculated and when appropriate data was pooled using Meta-DiSc. Based on the available literature on the test characteristics of different imaging modalities and applying the Pauker-Kassirer method we developed a test-treatment threshold model.

RESULTS

Twenty-one studies were included encompassing 8,605 patients with weighted AA prevalence of 39.2%. Studies had variable quality using the QUADAS-2 tool with most studies at high risk of partial verification bias. We divided studies based on their inclusion criteria into two groups of "undifferentiated abdominal pain" and abdominal pain "suspected of AA." In patients with undifferentiated abdominal pain, history of "pain migration to right lower quadrant (RLQ)" (LR+ = 4.81, 95% confidence interval [CI] = 3.59-6.44) and presence of "cough/hop pain" in the physical examination (LR+ = 7.64, 95% CI = 5.94-9.83) were most strongly associated with AA. In patients suspected of AA none of the history or laboratory findings were strongly associated with AA. Rovsing's sign was the physical examination finding most strongly associated with AA (LR+ = 3.52, 95% CI = 2.65-4.68). Among different PAS cutoff points, PAS ≥ 9 (LR+ = 5.26, 95% CI = 3.34-8.29) was most associated with AA. None of the history, physical examination, laboratory tests findings, or PAS alone could rule in or rule out AA in patients with undifferentiated abdominal pain or those suspected of AA. ED-POCUS had LR+ of 9.24 (95% CI = 6.24-13.28) and LR- of 0.17 (95% CI = 0.09-0.30). Using our test-treatment threshold model, positive ED-POCUS could rule in AA without the use of CT and MRI, but negative ED-POCUS could not rule out AA.

CONCLUSION

Presence of AA is more likely in patients with undifferentiated abdominal pain migrating to the RLQ or when cough/hop pain is present in the physical examination. Once AA is suspected, no single history, physical examination, laboratory finding, or score attained on PAS can eliminate the need for imaging studies. Operating characteristics of ED-POCUS are similar to those reported for RUS in literature for diagnosis of AA. In ED patients suspected of AA, a positive ED-POCUS is diagnostic and obviates the need for CT or MRI while negative ED-POCUS is not enough to rule out AA.

Pediatric appendicitis: state of the art review

Appendicitis is a common cause of abdominal pain in children. The diagnosis and treatment of the disease have undergone major changes in the past two decades, primarily as a result of the application of an evidence-based approach. Data from several randomized controlled trials, large database studies, and meta-analyses have fundamentally affected patient care. The best diagnostic approach is a standardized clinical pathway with a scoring system and selective imaging. Non-operative management of simple appendicitis is a reasonable option in selected cases, with the caveat that data in children remain limited. A minimally invasive (laparoscopic) appendectomy is the current standard in US and European children's hospitals. This article reviews the current 'state of the art' in the evaluation and management of pediatric appendicitis.

Pediatric Appendicitis

Appendicitis is one of the most common surgical pathologies in children. It can present with right lower quadrant pain. Scoring systems in combination with selective imaging and surgical examination will diagnose most children with appendicitis. Clinical pathways should be used. Most surgical interventions for appendicitis are now almost exclusively laparoscopic, with trials demonstrating better outcomes for children who undergo index hospitalization appendectomies when perforated. Nonoperative management has a role in the treatment of both uncomplicated and complicated appendicitis. This article discusses the workup and management, modes of treatment, and continued areas of controversy in pediatric appendicitis.

The Influence of Age on the Diagnostic Performance of White Blood Cell Count and Absolute Neutrophil Count in Suspected Pediatric Appendicitis

OBJECTIVE

White blood cell (WBC) count and absolute neutrophil count (ANC) are a standard part of the evaluation of suspected appendicitis. Specific threshold values are utilized in clinical pathways, but the discriminatory value of WBC count and ANC may vary by age. The objective of this study was to investigate whether the diagnostic value of WBC count and ANC varies across age groups and whether diagnostic thresholds should be age-adjusted.

METHODS

This is a multicenter prospective observational study of patients aged 3-18 years who were evaluated for appendicitis. Receiver operator characteristic curves were developed to assess overall discriminative power of WBC count and ANC across three age groups: <5, 5-11, and 12-18 years of age. Diagnostic performance of WBC count and ANC was then assessed at specific cut-points.

RESULTS

A total of 2,133 patients with a median age of 10.9 years (interquartile range = 8.0-13.9 years) were studied. Forty-one percent had appendicitis. The area under the curve (AUC) for WBC count was 0.69 (95% confidence interval [CI] = 0.61 to 0.77) for patients < 5 years of age, 0.76 (95% CI = 0.73 to 0.79) for 5-11 years of age, and 0.83 (95% CI = 0.81 to 0.86) for 12-18 years of age. The AUCs for ANC across age groups mirrored WBC performance. At a commonly utilized WBC cut-point of 10,000/mm³ , the sensitivity decreased with increasing age: 95% (<5 years), 91% (5-11 years), and 89% (12-18 years) whereas specificity increased by age: 36% (<5 years), 49% (5-12 years), and 64% (12-18 years).

CONCLUSION

WBC count and ANC had better diagnostic performance with increasing age. Age-adjusted values of WBC count or ANC should be considered in diagnostic strategies for suspected pediatric appendicitis.

Test characteristics of common appendicitis scores with and without laboratory investigations: a prospective observational study

Background

Despite the poor independent test characteristics of the white blood cell count (WBC) and neutrophil count (NC) in identifying appendicitis, common clinical decision supports including the Pediatric Appendicitis Score (PAS) and Alvarado Score (AS), require the WBC and NC values. Moreover, blood tests cause discomfort/pain to children and require time for processing results. Scores based on clinical information alone may be of benefit in the pediatric population. The objective of our study was to determine the test characteristics of the PAS and the AS with and without laboratory investigations (mPAS, mAS respectively) as well as the Lintula Score.

Methods

A prospective cohort study of children aged 5–17 years presenting to a pediatric ED with suspected appendicitis. Clinical care of the patient was left to the managing physician. At risk for appendicitis was defined by PAS ≥6; AS ≥5; LS ≥16, as originally described; modified cutoffs were defined as mPAS ≥4; mAS ≥4. Appendicitis was defined as acute inflammation, rupture or abscess of the appendix on pathologic evaluation. Test characteristics for each of the 5 scores were calculated.

Results

Of the 180 eligible children, 102 (56.7 %) were female. The average age was 11.2 years (SD 3.1). Appendectomy was performed in 58 (32.2 %) of children, 55 (94.8 %) were positive. For the PAS and mPAS, sensitivity and negative predictive values were similar (80.0 %, 86.4 % vs 87.3 %, 85.1 % respectively). For the AS and mAS, sensitivity and negative predictive values were also similar (85.5 %, 87.1 % vs 83.6 %, 83.3 % respectively). Specificities in the PAS, mPAS, AS and mAS were low (56.0 %, 32.0 %, 43.2 %, 63.0 % respectively). Test characteristics of the LS were poor (59.3 %, 79.2 %, 55.2 %, 81.8 %).

Conclusions

A modified Alvarado and PAS can be used to screen for children at low risk of appendicitis who may be carefully observed at home without the need for laboratory investigation. Translation to primary care settings should evaluate generalizability and determine impact on referral patterns.

Electronic supplementary material

The online version of this article (doi:10.1186/s12887-016-0687-6) contains supplementary material, which is available to authorized users.

Biomarkers of acute appendicitis: systematic review and cost-benefit trade-off analysis

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.