1
|
Nandan R, Samie AU, Acharya SK, Goel P, Jain V, Dhua AK, Khan MA, Yadav DK. Pediatric Appendicitis Score or Ultrasonography? In Search of a Better Diagnostic Tool in Indian Children with Lower Abdominal Pain. Indian J Pediatr 2023; 90:1204-1209. [PMID: 35794512 DOI: 10.1007/s12098-022-04226-9] [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: 11/18/2021] [Accepted: 03/07/2022] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To prospectively assess the performance of pediatric appendicitis score (PAS) in diagnosing acute appendicitis in the children with lower abdominal pain and correlated with ultrasound findings; and to assess the impact of the PAS on clinical outcome and its efficacy in differentiating between complicated and uncomplicated appendicitis. METHODS A prospective study was done which included cases of lower abdominal pain. Appendectomy was done for PAS ≥ 6, and diagnosis was confirmed on histopathology. A receiver operator characteristic (ROC) curve was created to assess the PAS performance. The sensitivity, specificity, and accuracy of ultrasonography in diagnosing appendicitis were assessed, and analysis of agreement between ultrasonography and PAS score was done by kappa statistics. RESULTS Of 260 cases with lower abdominal pain, 205 were suspected of having appendicitis. One hundred fifty-nine had PAS ≥ 6. There were 2/159 (1.26%) cases of negative appendectomies and 2/46 (4.34%) cases of missed appendicitis. The mean PAS was significantly higher in patients with appendicitis than in those without appendicitis. The area under the ROC curve was 0.9925. Sensitivity, specificity, and positive and negative predictive value of PAS were 98.74%, 95.65%, 95.7% and 95.65%, respectively. Complicated appendicitis had significantly more PAS, fever, and cough tenderness than uncomplicated appendicitis. The sensitivity and specificity of ultrasonography were 86.79% and 17.39%, respectively. Agreement between ultrasonography-proven appendicitis and PAS-dependent appendicitis was weak. CONCLUSION PAS has high efficacy in diagnosing acute appendicitis. Clinical outcome was more favorable with the use of PAS. Ultrasonography should be used judiciously and in combination with clinical judgment.
Collapse
Affiliation(s)
- Ruchira Nandan
- Department of Pediatric Surgery, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Amat Us Samie
- Department of Pediatric Surgery, VMMC and Safdarjung Hospital, New Delhi, India
| | - Samir Kant Acharya
- Department of Pediatric Surgery, VMMC and Safdarjung Hospital, New Delhi, India
| | - Prabudh Goel
- Department of Pediatric Surgery, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Vishesh Jain
- Department of Pediatric Surgery, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Anjan Kumar Dhua
- Department of Pediatric Surgery, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Maroof Ahmad Khan
- Department of Biostatistics, All India Institute of Medical Sciences, New Delhi, India
| | - Devendra Kumar Yadav
- Department of Pediatric Surgery, All India Institute of Medical Sciences, New Delhi, 110029, India.
| |
Collapse
|
2
|
Keven A, Tekin AF, Arslan FZ, Özer H, Durmaz MS. Two-dimensional shear wave elastography can improve the diagnostic accuracy of ultrasonography in acute appendicitis. J Ultrasound 2023; 26:471-477. [PMID: 36273062 PMCID: PMC10247928 DOI: 10.1007/s40477-022-00735-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Accepted: 09/22/2022] [Indexed: 10/24/2022] Open
Abstract
AIM We aimed to evaluate the effectiveness of combining 2-dimensional shear wave elastography (2D-SWE) with ultrasonography (US) in diagnosing acute appendicitis in patients with suspected acute appendicitis. METHODS Clinical and laboratory findings, gray-scale US and 2D-SWE imaging features, operation information, and pathology results of 48 patients diagnosed with acute appendicitis who presented with right lower quadrant pain were prospectively evaluated. We compared the findings to the US and SWE imaging features of 79 asymptomatic patients. RESULTS Mean Alvarado score and appendix diameter were statistically significantly higher for acute appendicitis (p < 0.001). In patients with acute appendicitis, mesenteric lymphadenopathy and fat stranding were also more frequent (p < 0.001). The mean velocity and kPa values for appendix and mesenteric fat were statistically significantly higher in acute appendicitis (p < 0.001). CONCLUSION In the diagnosis of acute appendicitis, 2D-SWE increases the diagnostic performance of gray-scale US in the differentiation of inflamed and normal appendixes.
Collapse
Affiliation(s)
- Ayşe Keven
- Department of Radiology, Akdeniz University School of Medicine, Dumlupınar Bulvarı, Akdeniz Üniversitesi Hastanesi, Arapsuyu, 07059 Antalya, Turkey
| | - Ali Fuat Tekin
- Department of Radiology, Health Sciences University, Başakşehir Çam and Sakura City Hospital, Istanbul, Turkey
| | - Fatma Zeynep Arslan
- Department of Radiology, Health Sciences University, Başakşehir Çam and Sakura City Hospital, Istanbul, Turkey
| | - Halil Özer
- Department of Radiology, Selçuk University School of Medicine, Konya, Turkey
| | - Mehmet Sedat Durmaz
- Department of Radiology, Selçuk University School of Medicine, Konya, Turkey
| |
Collapse
|
3
|
Kaselas C, Florou M, Demiri C, Tsopozidi M, Anastasiadis K, Spyridakis I. Classification systems of acute appendicitis as an indicator for paediatric surgical consultation of children with acute abdominal pain. J Paediatr Child Health 2023; 59:360-364. [PMID: 36546400 DOI: 10.1111/jpc.16308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2022] [Accepted: 12/01/2022] [Indexed: 12/24/2022]
Abstract
AIM This study examined if the classification systems for acute appendicitis could be applied in the emergency department as an indicator for surgical consultation, in order to reduce unnecessary paediatric surgery admission. METHODS The Alvarado Score (ALS) and the Pediatric Appendicitis Score (PAS) were applied. The decisions for hospitalisation and treatment were made independent of the scores. RESULTS In total, 307 children with abdominal pain suggestive of acute appendicitis were included. We used a cut-off point of 7 and divided the patients into groups; the group with score ≥ 7 points was considered the positive ALS and/or PAS group, and the group with score < 7 points was the negative ALS and/or PAS group. The same process for cut-values set at 6 points was followed. The joint probabilities for the 7-point-thresholds were: ALS-sensitivity 84%, PAS-sensitivity 85%, ALS-specificity 92%, PAS-specificity 92%, ALS-positive predictive value (PPV) 83%, PAS-PPV 84% and 93% negative predictive value (NPV) for both scores. Considering the 6-point-thresholds, we estimated: 94% sensitivity for both scores, 74% ALS-specificity, 84% PAS-specificity, 66% ALS-PPV, 73% PAS-PPV, 91% ALS-NPV and 97% PAS-NPV. CONCLUSION The scoring systems provided acceptable prediction of patients with and without appendicitis. They may be of use in the emergency department, as assistive diagnostic-tools, in order to reduce paediatric surgery consultations, admissions and treatment costs.
Collapse
Affiliation(s)
- Christos Kaselas
- Second Pediatric Surgery Department, Aristotle University of Thessaloniki, "Papageorgiou" General Hospital of Thessaloniki, Thessaloniki, Greece
| | - Maria Florou
- Second Pediatric Surgery Department, Aristotle University of Thessaloniki, "Papageorgiou" General Hospital of Thessaloniki, Thessaloniki, Greece
| | - Charikleia Demiri
- Second Pediatric Surgery Department, Aristotle University of Thessaloniki, "Papageorgiou" General Hospital of Thessaloniki, Thessaloniki, Greece
| | - Maria Tsopozidi
- Second Pediatric Surgery Department, Aristotle University of Thessaloniki, "Papageorgiou" General Hospital of Thessaloniki, Thessaloniki, Greece
| | - Kleanthis Anastasiadis
- Second Pediatric Surgery Department, Aristotle University of Thessaloniki, "Papageorgiou" General Hospital of Thessaloniki, Thessaloniki, Greece
| | - Ioannis Spyridakis
- Second Pediatric Surgery Department, Aristotle University of Thessaloniki, "Papageorgiou" General Hospital of Thessaloniki, Thessaloniki, Greece
| |
Collapse
|
4
|
Ahmad Mir S, Din Wani M. Shabir's "SMART-LAB" score for predicting complicated appendicitis-a prospective study. Turk J Surg 2022; 38:140-148. [PMID: 36483176 PMCID: PMC9714658 DOI: 10.47717/turkjsurg.2022.5383] [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: 06/25/2021] [Accepted: 05/12/2022] [Indexed: 12/24/2022]
Abstract
OBJECTIVES Complicated appendicitis needs an aggressive and urgent management, hence there is need of an efficient scoring system for predicting complicated appendicitis. With this in mind, the author developed the present scoring system for predicting complicated acute appendicitis. The study aimed to assess the suitability of this novel (Shabir's SMART-LAB) score for predicting diagnosis of complicated appendicitis. MATERIAL AND METHODS In this prospective study, a novel score designated as "SMART-LAB" SCORE, proposed by the author (Shabir) based on his previous observations was calculated in all patients. This score includes sonography (S), migratory right iliac fossa pain (M), anorexia (A), rebound tenderness (R), tenderness (T), leukocytosis (L), Acute phase protein-CRP (A), and serum bilirubin (B). RESULTS Of a total of 150 patients included in this study, 52 cases turned out to be perforated and/or gangrenous appendicitis on intraoperative/histopathologic examination. The most commonly affected age group was 10-19 years. SMART-LAB score of >9 was present in significantly higher number of patients in complicated (perforated and gangrenous) appendicitis than uncomplicated appendicitis (p value<0.001 i.e., highly significant). Hence, high likelihood of complicated appendicitis is reflected by a score >9 (with a sensitivity= 80.7%, specificity= 92.9%, PPV= 85.7%, NPV= 90.1%, and accuracy= 88.7%), while a score 7-9 needs further confirmation to reach a conclusion, and for a score of <7, there is low likelihood of complicated appendicitis. CONCLUSION It seems that this novel score (Shabir's SMART-LAB score) is a reasonably good tool to predict the diagnosis of complicated appendicitis. Early diagnosis of appendiceal perforation is important to limit the associated abdominal sepsis.
Collapse
Affiliation(s)
- Shabir Ahmad Mir
- Department of Surgery, Government Medical College Srinagar, Kashmir, India
| | - Mumtaz Din Wani
- Department of Surgery, Government Medical College Srinagar, Kashmir, India
| |
Collapse
|
5
|
Zhan Y, Wu M, Li K, Chen Q, Li N, Zheng W, Zhu Y, Peng X, Zhang S, Tao Q. Development and Validation of a Differential Diagnosis Model for Acute Appendicitis and Henoch-Schonlein Purpura in Children. PEDIATRIC ALLERGY, IMMUNOLOGY, AND PULMONOLOGY 2022; 35:86-94. [PMID: 35723658 DOI: 10.1089/ped.2021.0218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Objective: To study and develop a predictive model for the differential diagnosis of acute appendicitis (AA) and Henoch-Schonlein purpura (HSP) in children and to validate the model internally and externally. Methods: The complete data of AA and HSP cases were retrospectively analyzed and divided into internal and external verification groups. SPSS software was used for single-factor analysis and screening of independent variables, and R software was used for the development and verification of the diagnostic model. Lasso regression analysis was used to screen predictors and Lasso-logistic regression model was constructed, and K-fold cross-validation was used for the internal verification. In addition, nonfever patients were selected for model development and validation in the same way. Receiver operating characteristic (ROC) curves and calibration curves were drawn, respectively, to evaluate the 2 models. Results: Internal development and validation of the model showed that fever, neutrophil ratio (NEUT%), albumin (ALB), direct bilirubin (DBIL), C-reactive protein (CRP), and K were predictive factors for the diagnosis of HSP. The model was presented in the form of a nomogram, and the area under ROC curve of the development group and verification group was 0.9462 (95% confidence interval [CI] = 0.9402-0.9522) and 0.8931 (95% CI = 0.8724-0.9139), respectively. In the model of patients without fever, NEUT%, platelets (PLT), ALB, DBIL, alkaline phosphatase (ALP), CRP, and K were predictive factors for the diagnosis of HSP, and the area under ROC curve of the development group and verification group was 0.9186 (95% CI = 0.908-0.9293) and 0.8591 (95% CI = 0.8284-0.8897), respectively. Conclusion: In this study, 2 diagnostic models were constructed for fever or not, both of which had good discrimination and calibration, and were helpful to distinguish AA and HSP in children.
Collapse
Affiliation(s)
- Yishan Zhan
- Department of General Surgery, Affiliated Children's Hospital of Nanchang University, Nanchang, China.,Department of Pediatric Intensive Care Unit, Affiliated Children's Hospital of Nanchang University, Nanchang, China
| | - Min Wu
- Department of General Surgery, Affiliated Children's Hospital of Nanchang University, Nanchang, China
| | - Kehao Li
- Department of General Surgery, Affiliated Children's Hospital of Nanchang University, Nanchang, China
| | - Qiang Chen
- Department of Pediatric Intensive Care Unit, Affiliated Children's Hospital of Nanchang University, Nanchang, China
| | - Nuoya Li
- Department of General Surgery, Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Weiming Zheng
- Department of Nephrology, Affiliated Children's Hospital of Nanchang University, Nanchang, China
| | - Yourong Zhu
- Department of Pediatric Intensive Care Unit, Affiliated Children's Hospital of Nanchang University, Nanchang, China
| | - Xiaojie Peng
- Department of Nephrology, Affiliated Children's Hospital of Nanchang University, Nanchang, China
| | - Shouhua Zhang
- Department of General Surgery, Affiliated Children's Hospital of Nanchang University, Nanchang, China.,Department of General Surgery, Jiangxi Provincial Children's Hospital, Nanchang, China
| | - Qiang Tao
- Department of General Surgery, Affiliated Children's Hospital of Nanchang University, Nanchang, China.,Department of General Surgery, Jiangxi Provincial Children's Hospital, Nanchang, China
| |
Collapse
|
6
|
BOSTANCI MT, YILMAZ İ, CİMEN S, KOŞMAZ K, GÖKCE A, AVCI MA. Are scoring systems detecting acute appendicitis reliable? a prospective clinical study. JOURNAL OF HEALTH SCIENCES AND MEDICINE 2022. [DOI: 10.32322/jhsm.990183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
|
7
|
Abstract
INTRODUCTION The rate of misdiagnosis of appendicitis in children is a challenge and clinical prediction scores could be part of the solution. However, the pediatric appendicitis score (PAS) and the Alvarado score have shown disappointing diagnostic accuracy in pediatric validation studies, while the appendicitis inflammatory response (AIR) score and the novel pediatric appendicitis risk calculator (pARC) have not yet been validated thoroughly. Therefore, the aim of the present study was to evaluate these four prediction scores prospectively in children with suspected appendicitis. MATERIALS AND METHODS A prospective study was conducted over a 2-year period. All patients <15 years with suspected appendicitis were eligible for inclusion. The four prediction scores were compared regarding predictive values, receiver operating characteristics (ROC) curves, decision curve analysis, and clinical outcome. RESULTS Of the 318 patients included, 151 (47 %) patients had appendicitis. The AIR score and the pARC had substantially higher specificity and positive predictive value, and lower rate of false positives (7% and 2%), than the PAS and Alvarado score (36 and 28%, p < 0.001). Across the different gender and age groups, the AIR score and the pARC generally had fewer false positives than the PAS and Alvarado score. There were no significant differences in sensitivity, negative predictive values, rates of missed appendicitis, or ROC curve analysis. In decision curve analysis, the AIR score and the pARC outperformed the PAS and Alvarado score at most threshold probabilities. CONCLUSION The AIR score and the pARC are superior to the PAS and Alvarado score in diagnosing children with suspected appendicitis.
Collapse
|
8
|
Bakshi S, Mandal N. Evaluation of role of hyperbilirubinemia as a new diagnostic marker of complicated appendicitis. BMC Gastroenterol 2021; 21:42. [PMID: 33509122 PMCID: PMC7844962 DOI: 10.1186/s12876-021-01614-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Accepted: 01/14/2021] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND In appendicitis, elevated intra-luminal pressure and ischemic necrosis of mucosa causes tissue gangrene or perforation. This leads to cytotoxin facilitated progressive bacterial invasion or translocation into the hepatic parenchyma through portal system. This phenomenon interferes with the bilirubin excretion into the bile canaliculi. In the present study, establishment of a possible role of hyperbilirubinemia as a marker of gangrenous/perforated appendicitis has been studied. METHODS After matching the inclusion and exclusion criteria, all cases of clinically diagnosed acute appendicitis were taken for this prospective, single center, observational study. Per-operative diagnosis was confirmed by histopathological examination. RESULTS Out of 110 subjects of acute appendicitis 41 subjects (37.27%) had hyperbilirubinemia. Out of 35 subjects diagnosed as complicated appendicitis 32 subjects (91.42%) had raised total bilirubin levels, while the remaining 03 (8.58%) had normal levels. Among 75 subjects diagnosed as acute simple appendicitis 09 subjects (12%) had raised total bilirubin level, while the remaining 66 subjects (88%) had normal levels. It was Mixed Type of Hyperbilirubinemia in gangrenous/perforated appendicitis. The sensitivity of Total serum bilirubin in predicting complicated appendicitis was found 91.43% (76.942% to 98.196%), where as the specificity of this test was 88.00% (78.439% to 94.363%). positive predictive value and negative predictive value were 78.03% and 95.65% respectively. Positive likelihood ratio and negative likelihood ratio were found to be 7.619 and 0.097 respectively taking prevalence of complicated appendicitis be 31.80%. Receiver Operating Characteristic curve was obtained which shows optimal criterion at Total Bilirubin Level 1.06 mg/dl where sensitivity was 91.43% and specificity was 97.33% at 95% confidence interval with 31.8% disease prevalence. CONCLUSIONS This is to conclude that Serum bilirubin level estimation, which is a simple, cheap and easily available laboratory test, can be added to the routine investigations in clinically suspected cases of acute appendicitis for early diagnosis of complications. Trial registration Registered with Clinical Trials Registry-India (ICMR-NIMS) with Registration number CTRI/2019/05/018879 Dated 01/05/2019. This was a prospective trial. Trial URL: http://ctri.nic.in/Clinicaltrials/pdf_generate.php?trialid=33113&EncHid=99780.32960&modid=1&compid=19%27,%2733113det%27 .
Collapse
Affiliation(s)
- Sabyasachi Bakshi
- Department of General Surgery, Bankura Sammilani Medical College and Hospital, Bankura, West Bengal, 722102, India. .,, Kathghara Lane, Sonatuli, PO, Hooghly, West Bengal, 712103, India.
| | - Nilay Mandal
- Department of General Surgery, Bankura Sammilani Medical College and Hospital, Bankura, West Bengal, 722102, India
| |
Collapse
|
9
|
Lin W, Han W, Wen K, Huang S, Tang Y, Lin Z, Han M. The Alterations of Copper and Zinc Homeostasis in Acute Appendicitis and the Clinical Significance. Biol Trace Elem Res 2019; 192:116-122. [PMID: 30771140 DOI: 10.1007/s12011-019-01661-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Accepted: 02/04/2019] [Indexed: 02/05/2023]
Abstract
Copper (Cu) and zinc (Zn) are involved in inflammatory process. This study was to investigate the clinical significance of Cu and Zn homeostasis alterations in acute appendicitis (AA). One hundred twenty-two AA patients and 102 healthy controls were enrolled in this study. Of which, 85 patients' appendixes were collected after appendectomy. Another six appendixes from colon cancer patients were collected as tissue controls. The contents of Cu and Zn in serum or appendix were detected, and the Cu to Zn ratio (CZr) was calculated. The concentrations of serum ceruloplasmin (CP), Cu/Zn superoxide dismutase (SOD1), interleukin-6 (IL-6), and interleukin-22 in serum were measured, as well as the activity of CP and SOD1. The serum Zn concentration and SOD1 activity, appendix contents of Cu and Zn significantly decreased in AA patients, compared with those of controls, while serum CZr, concentrations of CP, SOD1, and IL-6, as well as CP activity increased significantly in AA patients. Additionally, serum concentrations of Zn, CP, CZr, or SOD1 activity varied in different pathological types of AA. Indicators such as serum SOD1 activity might serve as predictors for pathological classification before surgery. The serum Zn and CZr may be helpful for diagnosis of pure AA. The Cu and Zn homeostasis was altered in AA patients, which might contribute to inflammatory process of AA.
Collapse
Affiliation(s)
- Wenhao Lin
- Emergency Department of Second Affiliated Hospital, Shantou University Medical College, Shantou, China
| | - Wei Han
- Emergency Department of Shenzhen University General Hospital, Shenzhen, China
| | - Ke Wen
- Department of Microsurgery, Taihe Hospital, Shiyan, China
| | - Sunhua Huang
- Emergency Department of Second Affiliated Hospital, Shantou University Medical College, Shantou, China
| | - Yao Tang
- Emergency Department of Second Affiliated Hospital, Shantou University Medical College, Shantou, China
| | - Zhexuan Lin
- Bio-analytical Laboratory, Shantou University Medical College, Shantou, China.
| | - Ming Han
- Emergency Department of Shenzhen University General Hospital, Shenzhen, China.
| |
Collapse
|
10
|
van Amstel P, Gorter RR, van der Lee JH, Cense HA, Bakx R, Heij HA. Ruling out Appendicitis in Children: Can We Use Clinical Prediction Rules? J Gastrointest Surg 2019; 23:2027-2048. [PMID: 30374814 PMCID: PMC6773677 DOI: 10.1007/s11605-018-3997-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2018] [Accepted: 09/23/2018] [Indexed: 01/31/2023]
Abstract
PURPOSE To identify available clinical prediction rules (CPRs) and investigate their ability to rule out appendicitis in children presenting with abdominal pain at the emergency department, and accordingly select CPRs that could be useful in a future prospective cohort study. METHODS A literature search was conducted to identify available CPRs. These were subsequently tested in a historical cohort from a general teaching hospital, comprising all children (< 18 years) that visited the emergency department between 2012 and 2015 with abdominal pain. Data were extracted from the electronic patient files and scores of the identified CPRs were calculated for each patient. The negative likelihood ratios were only calculated for those CPRs that could be calculated for at least 50% of patients. RESULTS Twelve CPRs were tested in a cohort of 291 patients, of whom 87 (29.9%) suffered from acute appendicitis. The Ohmann score, Alvarado score, modified Alvarado score, Pediatric Appendicitis score, Low-Risk Appendicitis Rule Refinement, Christian score, and Low Risk Appendicitis Rule had a negative likelihood ratio < 0.1. The Modified Alvarado Scoring System and Lintula score had a negative likelihood ratio > 0.1. Three CPRs were excluded because the score could not be calculated for at least 50% of patients. CONCLUSION This study identified seven CPRs that could be used in a prospective cohort study to compare their ability to rule out appendicitis in children and investigate if clinical monitoring and re-evaluation instead of performing additional investigations (i.e., ultrasound) is a safe treatment strategy in case there is low suspicion of appendicitis.
Collapse
Affiliation(s)
- Paul van Amstel
- Paediatric Surgical Centre of Amsterdam, Emma Children’s Hospital Amsterdam University Medical Centre, P.O. Box 22660, 1100 DD Amsterdam, The Netherlands
| | - Ramon R. Gorter
- Paediatric Surgical Centre of Amsterdam, Emma Children’s Hospital Amsterdam University Medical Centre, P.O. Box 22660, 1100 DD Amsterdam, The Netherlands
| | - Johanna H. van der Lee
- Division Woman and Child, Amsterdam University Medical Centre, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Huib A. Cense
- Division of Surgery, Red Cross Hospital, Vondellaan 13, 1942 LE Beverwijk, The Netherlands
| | - Roel Bakx
- Paediatric Surgical Centre of Amsterdam, Emma Children’s Hospital Amsterdam University Medical Centre, P.O. Box 22660, 1100 DD Amsterdam, The Netherlands
| | - Hugo A. Heij
- Paediatric Surgical Centre of Amsterdam, Emma Children’s Hospital Amsterdam University Medical Centre, P.O. Box 22660, 1100 DD Amsterdam, The Netherlands
| |
Collapse
|
11
|
Cotton DM, Vinson DR, Vazquez-Benitez G, Margaret Warton E, Reed ME, Chettipally UK, Kene MV, Lin JS, Mark DG, Sax DR, McLachlan ID, Rauchwerger AS, Simon LE, Kharbanda AB, Kharbanda EO, Ballard DW. Validation of the Pediatric Appendicitis Risk Calculator (pARC) in a Community Emergency Department Setting. Ann Emerg Med 2019; 74:471-480. [PMID: 31229394 PMCID: PMC8364751 DOI: 10.1016/j.annemergmed.2019.04.023] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Revised: 03/21/2019] [Accepted: 04/19/2019] [Indexed: 12/29/2022]
Abstract
STUDY OBJECTIVE The pediatric Appendicitis Risk Calculator (pARC) is a validated clinical tool for assessing a child's probability of appendicitis. Our objective was to assess the performance of the pARC in community emergency departments (EDs) and to compare its performance with that of the Pediatric Appendicitis Score (PAS). METHODS We conducted a prospective validation study from October 1, 2016, to April 30, 2018, in 11 community EDs serving general populations. Patients aged 5 to 20.9 years and with a chief complaint of abdominal pain and less than or equal to 5 days of right-sided or diffuse abdominal pain were eligible for study enrollment. Our primary outcome was the presence or absence of appendicitis within 7 days of the index visit. We reported performance characteristics and secondary outcomes by pARC risk strata and compared the receiver operator characteristic (ROC) curves of the PAS and pARC. RESULTS We enrolled 2,089 patients with a mean age of 12.4 years, 46% of whom were male patients. Appendicitis was confirmed in 353 patients (16.9%), of whom 55 (15.6%) had perforated appendixes. Fifty-four percent of patients had very low (<5%) or low (5% to 14%) predicted risk, 43% had intermediate risk (15% to 84%), and 4% had high risk (≥85%). In the very-low- and low-risk groups, 1.4% and 3.0% of patients had appendicitis, respectively. The area under the ROC curve was 0.89 (95% confidence interval 0.87 to 0.92) for the pARC compared with 0.80 (95% confidence interval 0.77 to 0.82) for the PAS. CONCLUSION The pARC accurately assessed appendicitis risk for children aged 5 years and older in community EDs and the pARC outperformed the PAS.
Collapse
Affiliation(s)
- Dale M Cotton
- Permanente Medical Group, Oakland, CA; Kaiser Permanente, South Sacramento Medical Center, Sacramento, CA.
| | - David R Vinson
- Permanente Medical Group, Oakland, CA; Kaiser Permanente, Division of Research, Oakland, CA; Kaiser Permanente, Sacramento Medical Center, Sacramento, CA
| | | | | | - Mary E Reed
- Kaiser Permanente, Division of Research, Oakland, CA
| | - Uli K Chettipally
- Permanente Medical Group, Oakland, CA; Kaiser Permanente, South San Francisco Medical Center, South San Francisco, CA
| | - Mamata V Kene
- Permanente Medical Group, Oakland, CA; Kaiser Permanente, San Leandro Medical Center, San Leandro, CA
| | - James S Lin
- Permanente Medical Group, Oakland, CA; Kaiser Permanente, Santa Clara Medical Center, Santa Clara, CA
| | - Dustin G Mark
- Permanente Medical Group, Oakland, CA; Kaiser Permanente, Division of Research, Oakland, CA; Kaiser Permanente, Oakland Medical Center, Oakland, CA
| | - Dana R Sax
- Permanente Medical Group, Oakland, CA; Kaiser Permanente, Oakland Medical Center, Oakland, CA
| | - Ian D McLachlan
- Permanente Medical Group, Oakland, CA; Kaiser Permanente, San Francisco Medical Center, San Francisco, CA
| | | | - Laura E Simon
- Kaiser Permanente, Division of Research, Oakland, CA
| | - Anupam B Kharbanda
- Children's Hospitals and Clinics of Minnesota, Department of Pediatric Emergency Medicine, Minneapolis, MN
| | | | - Dustin W Ballard
- Permanente Medical Group, Oakland, CA; Kaiser Permanente, Division of Research, Oakland, CA; Kaiser Permanente, San Rafael Medical Center, San Rafael, CA
| |
Collapse
|
12
|
Lee WH, O'Brien S, Skarin D, Cheek JA, Deitch J, Nataraja R, Craig S, Borland ML. Accuracy of clinician gestalt in diagnosing appendicitis in children presenting to the emergency department. Emerg Med Australas 2019; 31:612-618. [PMID: 30665265 DOI: 10.1111/1742-6723.13220] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2018] [Revised: 11/09/2018] [Accepted: 11/29/2018] [Indexed: 12/29/2022]
Abstract
OBJECTIVE Abdominal pain is a common paediatric presentation to the ED. Accurate diagnosis of acute appendicitis is challenging, with the best-performing clinical scoring systems having sensitivities between 72% and 100%. The aim of this study is to assess the diagnostic accuracy of clinician gestalt according to seniority in diagnosing paediatric acute appendicitis in ED. METHODS This is a prospective multi-centre observational study of clinician's prediction of appendicitis in children under the age of 16 years presenting to four EDs with abdominal pain over a 1 month period at each site. Clinician-estimated likelihood of acute appendicitis was compared with the final diagnosis determined by histopathology or operative findings and supplemented by telephone follow up for those without an operation. The primary outcome was diagnostic accuracy of clinician gestalt according to clinician seniority in diagnosing appendicitis. RESULTS There were 381 children enrolled with completed clinician questionnaires, and 224 children had complete follow up or underwent appendicectomy. The median age was 9 years (interquartile range 6-12) and the incidence of appendicitis was 31/224 (13.8%, 95% confidence interval 9.3-18.4). The area under the curve (AUC), sensitivity, specificity, positive predictive value and negative predictive value of clinician gestalt were 0.84 (0.76-0.91), 81% (63-93%), 76% (69-82%), 35% (28-42%) and 96% (92-98%), respectively, giving an overall diagnostic accuracy of 76% (70-82%). AUC stratified by clinician seniority (junior, intermediate and senior) were 0.89 (0.80-0.98), 0.82 (0.69-0.95) and 0.76 (0.56-0.96), respectively. CONCLUSIONS The diagnostic accuracy of ED clinician gestalt in paediatric appendicitis is comparable to current clinical scoring systems irrespective of seniority.
Collapse
Affiliation(s)
- Wei Hao Lee
- Emergency Department, Princess Margaret Hospital for Children, Perth, Western Australia, Australia
| | - Sharon O'Brien
- Emergency Department, Princess Margaret Hospital for Children, Perth, Western Australia, Australia
| | - Dmitry Skarin
- Emergency Department, Princess Margaret Hospital for Children, Perth, Western Australia, Australia
| | - John A Cheek
- Emergency Department, Royal Children's Hospital Melbourne, Melbourne, Victoria, Australia.,The University of Melbourne, Melbourne, Victoria, Australia.,Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Jessica Deitch
- Department of Medicine, Clinical Sciences at Monash Health, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
| | - Ramesh Nataraja
- Department of Paediatric Surgery, Monash Children's Hospital, Melbourne, Victoria, Australia.,Department of Paediatrics, Clinical Sciences at Monash Health, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
| | - Simon Craig
- Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Medicine, Clinical Sciences at Monash Health, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia.,Paediatric Emergency Department, Monash Medical Centre, Melbourne, Victoria, Australia
| | - Meredith L Borland
- Emergency Department, Princess Margaret Hospital for Children, Perth, Western Australia, Australia.,Divisions of Emergency Medicine and Paediatrics, School of Medicine, The University of Western Australia, Perth, Western Australia, Australia
| | | |
Collapse
|
13
|
Importance of Clinical Decision Making by Experienced Pediatric Surgeons When Children Are Suspected of Having Acute Appendicitis: The Reality in a High-Volume Pediatric Emergency Department. Pediatr Emerg Care 2017; 33:e38-e42. [PMID: 27331578 DOI: 10.1097/pec.0000000000000763] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVE The aim of the present study was to compare the pediatric appendicitis score (PAS), the Alvarado score (AS), white blood cell count (WBC), absolute neutrophil count (ANC), C-reactive protein (CRP) level, procalcitonin level, and ultrasound (US) data, with the appendectomy decisions of pediatric surgeons diagnosing acute appendicitis (AA) in a real-life setting; this was a top-level, high-volume pediatric emergency department (PED) in a developing country. METHODS The study was conducted prospectively between January 2012 and June 2013 in the PED of the Tepecik Teaching and Research Hospital in Izmir, Turkey. The study was observational in nature; no attempt was made to influence indications for exploration or the timing thereof. Children aged 4 to 18 years presenting to the PED on suspicion of AA were included. The WBC, ANC, CRP level, and procalcitonin level were measured, and US was performed on all patients on admission. The PAS and AS were calculated. An operative decision was made by each pediatric surgeon who had the results of laboratory and radiological tests. The criterion standard for AA was histopathological assessment. RESULTS Upon receiver operating curve (ROC) analysis, the areas under the ROCs (AUROCs) of the WBC, ANC, CRP level, procalcitonin level, US positivity, PAS, AS, and decisions of pediatric surgeons supported by laboratory and US data were 0.734, 0.741, 0.671, 0.675, 0.670, 0.831, 0.794, and 0.910, respectively. When US data were employed only in cases with PASs 4 to 7, the sensitivity increased but specificity decreased. The sensitivity and specificity of pediatric surgical decisions were 100% and 82.50%, respectively. The difference between the PAS AUROC and the pediatric surgeon decision-making AUROC was significant (P = 0.0393; 95% confidence interval, 0.0470-0.226). CONCLUSIONS Good pediatric surgical decision making supported by laboratory and US data for those suspected of AA may be the most effective diagnostic tool in a high-volume PED in a developing country.
Collapse
|
14
|
Chisalau V, Tica C, Chirila S, Ionescu C. Alvarado score: can it reduce unnecessary interventions for acute appendicitis in children? ARS MEDICA TOMITANA 2017. [DOI: 10.1515/arsm-2017-0020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Abstract
The purpose of the study is to compare the outcomes of surgical interventions for acute appendicitis with the values of the Alvarado score. We conducted the study on 572 patients that underwent surgical interventions for acute appendicitis. Retrospectively, based on the medical records, we calculated the MANTRELS score and compared the outcomes of the intervention with the values of the applied score. Almost one third of the patients with a MANTRELS score lower than 6 had negative appendectomies. These patients represent 60% of the total cases of negative appendectomies, while in the case of patients with a high score around 2% had negative appendectomies. We concluded that using this scoring system to assess the need of immediate surgical intervention is important and can increase the rate of positive diagnosis mainly by limiting the number of unnecessary interventions.
Collapse
Affiliation(s)
- V. Chisalau
- Emergency County Hospital Piatra Neamt, Piatra Neamt , Romania
| | - C. Tica
- Faculty of Medicine, University “Ovidius” of Constanta, Constanta , Romania
| | - S. Chirila
- Faculty of Medicine, University "Ovidius" of Constanta Universitatii Alle No. 1, Campus B, Constanta , Romania
| | - C. Ionescu
- Faculty of Medicine, University “Ovidius” of Constanta, Constanta , Romania
| |
Collapse
|
15
|
Computed Tomography Utilization for the Diagnosis of Acute Appendicitis in Children Decreases With a Diagnostic Algorithm. Ann Surg 2017; 264:474-81. [PMID: 27433918 DOI: 10.1097/sla.0000000000001867] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The primary objective of this project was to decrease computed tomography (CT) utilization for the diagnosis of appendicitis in an academic children's hospital emergency department (ED) through a multidisciplinary quality improvement initiative. BACKGROUND Appendicitis is the most common abdominal diagnosis leading to the hospitalization of children in the United States. However, the diagnosis of appendicitis in children can be difficult and many centers rely heavily upon CT scans. Recent recommendations emphasize decreasing CT use among pediatric patients because of an increased lifetime risk of radiation-induced malignancies. METHODS A retrospective review was conducted of patients diagnosed with appendicitis in the ED at Children's Mercy Hospital from January 1, 2011 to February 28, 2014 to establish a baseline cohort. From August 1, 2014 to July 31, 2015, a newly designed diagnostic algorithm was used in the ED and patients were prospectively followed. Any patient discharged from the ED received a follow-up phone call. Patients treated for appendicitis before and after pathway implementation were compared. In addition, any patient evaluated for appendicitis after implementation of the algorithm was analyzed for adherence to the clinical pathway. Differences between the 2 groups were analyzed using ANOVA, Wilcoxon Rank Sum, χ, and Fisher Exact tests. RESULTS Of 840 patients seen after implementation of the diagnostic algorithm, 267 were diagnosed with appendicitis. After implementation of the algorithm, CT utilization decreased from 75.4% to 24.2% (P < 0.0001) in patients with appendicitis. CT utilization was 27.3% after implementation, regardless of the ultimate diagnosis or algorithm adherence. The diagnostic pathway had a sensitivity of 98.6% and specificity of 94.4%. CONCLUSIONS Implementation of a diagnostic algorithm for appendicitis in children significantly decreases CT utilization, whereas maintaining a high sensitivity and specificity.
Collapse
|
16
|
Benabbas R, Hanna M, Shah J, Sinert R. Diagnostic Accuracy of History, Physical Examination, Laboratory Tests, and Point-of-care Ultrasound for Pediatric Acute Appendicitis in the Emergency Department: A Systematic Review and Meta-analysis. Acad Emerg Med 2017; 24:523-551. [PMID: 28214369 DOI: 10.1111/acem.13181] [Citation(s) in RCA: 110] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2016] [Revised: 01/17/2017] [Accepted: 02/06/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND Acute appendicitis (AA) is the most common surgical emergency in children. Accurate and timely diagnosis is crucial but challenging due to atypical presentations and the inherent difficulty of obtaining a reliable history and physical examination in younger children. OBJECTIVES The aim of this study was to determine the utility of history, physical examination, laboratory tests, Pediatric Appendicitis Score (PAS) and Emergency Department Point-of-Care Ultrasound (ED-POCUS) in the diagnosis of AA in ED pediatric patients. We performed a systematic review and meta-analysis and used a test-treatment threshold model to identify diagnostic findings that could rule in/out AA and obviate the need for further imaging studies, specifically computed tomography (CT) scan, magnetic resonance imaging (MRI), and radiology department ultrasound (RUS). METHODS We searched PubMed, EMBASE, and SCOPUS up to October 2016 for studies on ED pediatric patients with abdominal pain. Quality Assessment Tool for Diagnostic Accuracy Studies (QUADAS-2) was used to evaluate the quality and applicability of included studies. Positive and negative likelihood ratios (LR+ and LR-) for diagnostic modalities were calculated and when appropriate data was pooled using Meta-DiSc. Based on the available literature on the test characteristics of different imaging modalities and applying the Pauker-Kassirer method we developed a test-treatment threshold model. RESULTS Twenty-one studies were included encompassing 8,605 patients with weighted AA prevalence of 39.2%. Studies had variable quality using the QUADAS-2 tool with most studies at high risk of partial verification bias. We divided studies based on their inclusion criteria into two groups of "undifferentiated abdominal pain" and abdominal pain "suspected of AA." In patients with undifferentiated abdominal pain, history of "pain migration to right lower quadrant (RLQ)" (LR+ = 4.81, 95% confidence interval [CI] = 3.59-6.44) and presence of "cough/hop pain" in the physical examination (LR+ = 7.64, 95% CI = 5.94-9.83) were most strongly associated with AA. In patients suspected of AA none of the history or laboratory findings were strongly associated with AA. Rovsing's sign was the physical examination finding most strongly associated with AA (LR+ = 3.52, 95% CI = 2.65-4.68). Among different PAS cutoff points, PAS ≥ 9 (LR+ = 5.26, 95% CI = 3.34-8.29) was most associated with AA. None of the history, physical examination, laboratory tests findings, or PAS alone could rule in or rule out AA in patients with undifferentiated abdominal pain or those suspected of AA. ED-POCUS had LR+ of 9.24 (95% CI = 6.24-13.28) and LR- of 0.17 (95% CI = 0.09-0.30). Using our test-treatment threshold model, positive ED-POCUS could rule in AA without the use of CT and MRI, but negative ED-POCUS could not rule out AA. CONCLUSION Presence of AA is more likely in patients with undifferentiated abdominal pain migrating to the RLQ or when cough/hop pain is present in the physical examination. Once AA is suspected, no single history, physical examination, laboratory finding, or score attained on PAS can eliminate the need for imaging studies. Operating characteristics of ED-POCUS are similar to those reported for RUS in literature for diagnosis of AA. In ED patients suspected of AA, a positive ED-POCUS is diagnostic and obviates the need for CT or MRI while negative ED-POCUS is not enough to rule out AA.
Collapse
Affiliation(s)
- Roshanak Benabbas
- Department of Emergency Medicine; State University of New York/SUNY Downstate Medical Center; Brooklyn NY
- Department of Emergency Medicine; Kings County Hospital Center; Brooklyn NY
| | - Mark Hanna
- Department of Pediatrics; State University of New York/SUNY Downstate Medical Center; Brooklyn NY
- Department of Pediatrics; Kings County Hospital Center; Brooklyn NY
| | - Jay Shah
- Department of Emergency Medicine; Kings County Hospital Center; Brooklyn NY
| | - Richard Sinert
- Department of Emergency Medicine; State University of New York/SUNY Downstate Medical Center; Brooklyn NY
- Department of Emergency Medicine; Kings County Hospital Center; Brooklyn NY
| |
Collapse
|
17
|
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.
Collapse
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
| |
Collapse
|
18
|
Almaramhy HH. Acute appendicitis in young children less than 5 years: review article. Ital J Pediatr 2017; 43:15. [PMID: 28257658 PMCID: PMC5347837 DOI: 10.1186/s13052-017-0335-2] [Citation(s) in RCA: 90] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2016] [Accepted: 01/19/2017] [Indexed: 12/29/2022] Open
Abstract
Despite wide spread availability of sophisticated diagnostic imaging, acute appendicitis in pre-school children remains a diagnostic challenge. Most of these children present late, often with complications e.g. appendicular perforation, abscess formation and peritonitis and as result hospital stay is prolonged and is associated with increased morbidity and mortality.The purpose of this article is to review peculiar features of acute appendicitis in preschool children.
Collapse
Affiliation(s)
- Hamdi Hameed Almaramhy
- Department of Surgery, College of Medicine, Taibah University, AL-Madinah Al-Munawarah, Kingdom of Saudi Arabia.
| |
Collapse
|
19
|
Depinet H, Copeland K, Gogain J, Hennes H, Paradis NA, Andrews-Dickert R, Vance CW, Huckins DS. Addition of a biomarker panel to a clinical score to identify patients at low risk for appendicitis. Am J Emerg Med 2016; 34:2266-2271. [DOI: 10.1016/j.ajem.2016.08.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2016] [Revised: 07/31/2016] [Accepted: 08/08/2016] [Indexed: 12/29/2022] Open
|
20
|
Evaluation of scoring systems in predicting acute appendicitis in children. Surgery 2016; 160:1599-1604. [PMID: 27528209 DOI: 10.1016/j.surg.2016.06.023] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2016] [Revised: 05/20/2016] [Accepted: 06/18/2016] [Indexed: 12/29/2022]
Abstract
BACKGROUND Acute appendicitis can be difficult to diagnose, especially in children. Appendicitis scoring systems have been developed as a diagnostic tool to improve the decision-making process in patients with suspected acute appendicitis. This study evaluates the Appendicitis Inflammatory Response score, Alvarado score, and Pediatric Appendicitis Score in children suspected of acute appendicitis. METHODS Data were collected retrospectively. All children younger than 18 years suspected of acute appendicitis who presented to the emergency department between January 2006 and June 2014 were included in this study. Variables were registered to evaluate 3 different appendicitis scoring systems. The diagnostic performance of the 3 scores was analyzed using the area under the receiver-operating curve and by calculating the diagnostic performances at different cut-off points. RESULTS The present study included 747 consecutive children. There were 399 boys (53%) and 348 girls (47%) with a mean age of 11 years (range, 1-17 years). In total, 269 children (36%) were diagnosed with acute appendicitis. The area under the receiver-operating curve of the Appendicitis Inflammatory Response score was 0.90, the Alvarado score was 0.87, and the Pediatric Appendicitis Score was 0.82 (P < .05, respectively). The specificity and positive predictive value of the Appendicitis Inflammatory Response score were better at predicting an acute appendicitis than that of the Alvarado score and Pediatric Appendicitis Score. In children with a low-risk acute appendicitis, false negative rates of 14% for the Appendicitis Inflammatory Response, 7% for the Alvarado, and 18% for the Pediatric Appendicitis Score were measured. CONCLUSION In this study, the Appendicitis Inflammatory Response score had the highest discriminating power and outperformed the Alvarado score and Pediatric Appendicitis Score in predicting acute appendicitis in children. Excluding acute appendicitis safely in children with the scoring systems still remains uncertain.
Collapse
|
21
|
Benito J, Acedo Y, Medrano L, Barcena E, Garay RP, Arri EA. Usefulness of new and traditional serum biomarkers in children with suspected appendicitis. Am J Emerg Med 2016; 34:871-6. [PMID: 26935221 DOI: 10.1016/j.ajem.2016.02.011] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Revised: 02/05/2016] [Accepted: 02/05/2016] [Indexed: 12/29/2022] Open
|
22
|
Scheller RL, Depinet HE, Ho ML, Hornung RW, Reed JL. Utility of Pediatric Appendicitis Score in Female Adolescent Patients. Acad Emerg Med 2016; 23:610-5. [PMID: 26824846 DOI: 10.1111/acem.12916] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2015] [Revised: 11/17/2015] [Accepted: 11/20/2015] [Indexed: 12/29/2022]
Abstract
OBJECTIVES Acute appendicitis is common in the pediatric population and is difficult to diagnose in adolescent females. The validated Pediatric Appendicitis Score (PAS) has unclear utility in female adolescents. The purpose of this study is to determine the sensitivity, specificity, negative predictive value (NPV), and positive predictive value (PPV) of the PAS for female adolescents compared to all other patients. METHODS This study examined a retrospective observational cohort of patients ages 3 to 21 years in a pediatric emergency department with prospectively assigned PAS from an existing database. We compared the sensitivity, specificity, PPV, and NPV of the PAS for acute appendicitis among female adolescent patients (13 to 21 years) and all other patients. RESULTS Of the 1,228 patients enrolled, 901 (73.4%) had a complete PAS. Among the 901 patients, 249 (27.6%) had pathology-proven appendicitis, 494 (54.8%) were female, and 272 (30.2%) were adolescent females. At a cutoff of ≥8, the PAS showed a specificity of 89% for adolescent females and 78% for all other patients (p < 0.001), although the specificities did not differ at a cutoff of ≥7. At both cutoffs, the PPVs were poor in both groups. At a cutoff of ≥3, the PAS showed similar sensitivities in both groups. At a cutoff of <3, the NPVs did not significantly differ between groups. CONCLUSION At a cutoff of ≥8 (although not ≥7), the PAS demonstrated a higher specificity among female adolescents compared to all other patients. The PPV for both cutoffs in both groups were poor. At a cutoff of ≥3, sensitivities were equivalent. The NPV for a cutoff of <3 was acceptable but similar in both groups. While sensitivities were similar to previously reported, specificities in both groups were lower. This highlights the need for further investigation of the PAS's performance in specific subpopulations.
Collapse
Affiliation(s)
- RoseAnn L. Scheller
- Division of Emergency Medicine; Cincinnati Children's Hospital Medical Center; Cincinnati OH
| | - Holly E. Depinet
- Division of Emergency Medicine; Cincinnati Children's Hospital Medical Center; Cincinnati OH
| | - Mona L. Ho
- Division of Emergency Medicine; Cincinnati Children's Hospital Medical Center; Cincinnati OH
| | - Richard W. Hornung
- Division of Emergency Medicine; Cincinnati Children's Hospital Medical Center; Cincinnati OH
| | - Jennifer L. Reed
- Division of Emergency Medicine; Cincinnati Children's Hospital Medical Center; Cincinnati OH
| |
Collapse
|
23
|
Golden SK, Harringa JB, Pickhardt PJ, Ebinger A, Svenson JE, Zhao YQ, Li Z, Westergaard RP, Ehlenbach WJ, Repplinger MD. Prospective evaluation of the ability of clinical scoring systems and physician-determined likelihood of appendicitis to obviate the need for CT. Emerg Med J 2016; 33:458-64. [PMID: 26935714 DOI: 10.1136/emermed-2015-205301] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2015] [Accepted: 02/10/2016] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To determine whether clinical scoring systems or physician gestalt can obviate the need for computed tomography (CT) in patients with possible appendicitis. METHODS Prospective, observational study of patients with abdominal pain at an academic emergency department (ED) from February 2012 to February 2014. Patients over 11 years old who had a CT ordered for possible appendicitis were eligible. All parameters needed to calculate the scores were recorded on standardised forms prior to CT. Physicians also estimated the likelihood of appendicitis. Test characteristics were calculated using clinical follow-up as the reference standard. Receiver operating characteristic curves were drawn. RESULTS Of the 287 patients (mean age (range), 31 (12-88) years; 60% women), the prevalence of appendicitis was 33%. The Alvarado score had a positive likelihood ratio (LR(+)) (95% CI) of 2.2 (1.7 to 3) and a negative likelihood ratio (LR(-)) of 0.6 (0.4 to 0.7). The modified Alvarado score (MAS) had LR(+) 2.4 (1.6 to 3.4) and LR(-) 0.7 (0.6 to 0.8). The Raja Isteri Pengiran Anak Saleha Appendicitis (RIPASA) score had LR(+) 1.3 (1.1 to 1.5) and LR(-) 0.5 (0.4 to 0.8). Physician-determined likelihood of appendicitis had LR(+) 1.3 (1.2 to 1.5) and LR(-) 0.3 (0.2 to 0.6). When combined with physician likelihoods, LR(+) and LR(-) was 3.67 and 0.48 (Alvarado), 2.33 and 0.45 (RIPASA), and 3.87 and 0.47 (MAS). The area under the curve was highest for physician-determined likelihood (0.72), but was not statistically significantly different from the clinical scores (RIPASA 0.67, Alvarado 0.72, MAS 0.7). CONCLUSIONS Clinical scoring systems performed equally well as physician gestalt in predicting appendicitis. These scores do not obviate the need for imaging for possible appendicitis when a physician deems it necessary.
Collapse
Affiliation(s)
- Sean K Golden
- BerbeeWalsh, Department of Emergency Medicine, University of Wisconsin-Madison, Wisconsin, USA
| | - John B Harringa
- BerbeeWalsh, Department of Emergency Medicine, University of Wisconsin-Madison, Wisconsin, USA
| | - Perry J Pickhardt
- Department of Radiology, University of Wisconsin-Madison, Wisconsin, USA
| | - Alexander Ebinger
- Department of Emergency Medicine, University of Colorado School of Medicine, Denver, Colorado, USA
| | - James E Svenson
- BerbeeWalsh, Department of Emergency Medicine, University of Wisconsin-Madison, Wisconsin, USA
| | - Ying-Qi Zhao
- Department of Biostatistics and Medical Informatics, University of Wisconsin, Madison, Wisconsin, USA
| | - Zhanhai Li
- Department of Biostatistics and Medical Informatics, University of Wisconsin, Madison, Wisconsin, USA
| | - Ryan P Westergaard
- Department of Medicine, University of Wisconsin, Madison, Wisconsin, USA
| | | | - Michael D Repplinger
- BerbeeWalsh, Department of Emergency Medicine, University of Wisconsin-Madison, Wisconsin, USA Department of Radiology, University of Wisconsin-Madison, Wisconsin, USA
| |
Collapse
|
24
|
Athans BS, Depinet HE, Towbin AJ, Zhang Y, Zhang B, Trout AT. Use of Clinical Data to Predict Appendicitis in Patients with Equivocal US Findings. Radiology 2016; 280:557-67. [PMID: 26878226 DOI: 10.1148/radiol.2016151412] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Purpose To determine the incremental value of clinical data in patients with ultrasonographic (US) examinations that were interpreted as being equivocal for acute appendicitis. Materials and Methods Institutional review board approval, with a waiver of informed consent, was obtained for this analysis of clinical and imaging data in patients younger than 18 years old who were evaluated for acute appendicitis. Findings from US examinations were reported in a structured fashion, including two possible equivocal impressions. Clinical data were captured as Pediatric Appendicitis (PAS) or Alvarado scores and considered as categoric (high, intermediate, or low likelihood) and continuous variables to simulate stratification of equivocal US examinations to predict appendicitis. Receiver operating characteristic curves were used to define score cutoffs, and logistic regression was used to assess individual clinical variables as predictors of appendicitis. Results The study population was made up of 776 patients (mean age, 11.7 years ± 3.7), with 429 (55.2%) girls. A total of 203 (26%) patients had appendicitis. US had a negative predictive value of 96.2% and a positive predictive value of 93.3% for depicting appendicitis, with 89 of 782 (11.4%) equivocal examinations. Categoric PAS and Alvarado scores were equivocal for 59.5% (53 of 89) and 50.6% (45 of 89) of equivocal US examinations, respectively. Categoric low- and high-likelihood PAS and Alvarado scores correctly predicted the presence of appendicitis in 61.1% (22 of 36) and 77.3% (34 of 44) of equivocal US examinations, respectively. As continuous variables, a PAS or Alvarado score of 5 or lower could be used to exclude appendicitis, with a 80.8% (21 of 26) and 90% (18 of 20) negative predictive value, respectively. Conclusion The study confirms the excellent performance of US for depicting pediatric appendicitis. In the subset of equivocal US examinations, a low clinical score (≤5) may be used to identify patients with a low likelihood of having appendicitis. (©) RSNA, 2016.
Collapse
Affiliation(s)
- Brett S Athans
- From the University of Cincinnati College of Medicine, Cincinnati, Ohio (B.S.A.); Division of Emergency Medicine (H.E.D.), Department of Radiology (A.J.T., A.T.T.), and Division of Biostatistics and Epidemiology (B.Z.), Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, MLC 5031, Cincinnati, OH 45229; and Department of Mathematical Sciences, University of Cincinnati, Cincinnati, Ohio (Y.Z.)
| | - Holly E Depinet
- From the University of Cincinnati College of Medicine, Cincinnati, Ohio (B.S.A.); Division of Emergency Medicine (H.E.D.), Department of Radiology (A.J.T., A.T.T.), and Division of Biostatistics and Epidemiology (B.Z.), Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, MLC 5031, Cincinnati, OH 45229; and Department of Mathematical Sciences, University of Cincinnati, Cincinnati, Ohio (Y.Z.)
| | - Alexander J Towbin
- From the University of Cincinnati College of Medicine, Cincinnati, Ohio (B.S.A.); Division of Emergency Medicine (H.E.D.), Department of Radiology (A.J.T., A.T.T.), and Division of Biostatistics and Epidemiology (B.Z.), Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, MLC 5031, Cincinnati, OH 45229; and Department of Mathematical Sciences, University of Cincinnati, Cincinnati, Ohio (Y.Z.)
| | - Yue Zhang
- From the University of Cincinnati College of Medicine, Cincinnati, Ohio (B.S.A.); Division of Emergency Medicine (H.E.D.), Department of Radiology (A.J.T., A.T.T.), and Division of Biostatistics and Epidemiology (B.Z.), Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, MLC 5031, Cincinnati, OH 45229; and Department of Mathematical Sciences, University of Cincinnati, Cincinnati, Ohio (Y.Z.)
| | - Bin Zhang
- From the University of Cincinnati College of Medicine, Cincinnati, Ohio (B.S.A.); Division of Emergency Medicine (H.E.D.), Department of Radiology (A.J.T., A.T.T.), and Division of Biostatistics and Epidemiology (B.Z.), Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, MLC 5031, Cincinnati, OH 45229; and Department of Mathematical Sciences, University of Cincinnati, Cincinnati, Ohio (Y.Z.)
| | - Andrew T Trout
- From the University of Cincinnati College of Medicine, Cincinnati, Ohio (B.S.A.); Division of Emergency Medicine (H.E.D.), Department of Radiology (A.J.T., A.T.T.), and Division of Biostatistics and Epidemiology (B.Z.), Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, MLC 5031, Cincinnati, OH 45229; and Department of Mathematical Sciences, University of Cincinnati, Cincinnati, Ohio (Y.Z.)
| |
Collapse
|
25
|
Pediatric Emergency Appendectomy and 30-Day Postoperative Outcomes in District General Hospitals and Specialist Pediatric Surgical Centers in England, April 2001 to March 2012. Ann Surg 2016; 263:184-90. [DOI: 10.1097/sla.0000000000001099] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
|
26
|
Bachur RG, Callahan MJ, Monuteaux MC, Rangel SJ. Integration of ultrasound findings and a clinical score in the diagnostic evaluation of pediatric appendicitis. J Pediatr 2015; 166:1134-9. [PMID: 25708690 DOI: 10.1016/j.jpeds.2015.01.034] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2014] [Revised: 12/08/2014] [Accepted: 01/20/2015] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To determine the predictive value of ultrasonography (US) for appendicitis in children when combined with clinical assessment based on the Pediatric Appendicitis Score (PAS). STUDY DESIGN Observational study of children aged 3-18 years who had an US examination for possible appendicitis. A PAS was calculated on the basis of historical elements, examination, and laboratory studies and was used to classify patients into 3 risk groups (low, medium, high). The predictive value of the PAS for appendicitis was calculated and stratified by the result of the US (positive, negative, or equivocal). RESULTS A total of 728 children with a median age 11.7 (IQR 7.8-14.9) years were studied; 29% had appendicitis. The negative predictive value of US decreased with increasing PAS-based risk assignment: low risk 1.00 (95% CI, 0.97-1.00), medium risk 0.94 (0.91-0.97), and high risk 0.81 (0.73-0.89). With increasing PAS, the positive predictive value increased: low risk 0.73 (0.47-0.99), medium risk 0.90 (0.82-0.98), and high risk 0.97 (0.95-1.0). Among children with equivocal ultrasound results, the proportion with appendicitis ranged from 0.09 (0.0-0.19) for low-risk patients to 0.47 (0.33-0.61) among for high-risk patients. CONCLUSION Ultrasound findings in children with possible appendicitis should be integrated with clinical assessment, such as a clinical score, to determine next steps in management. Rates of false-negative US increase with increasing PAS, and false-positive US results occur more often with lower PAS. When discordance exists between US results and the clinical assessment, serial examinations or further imaging are warranted.
Collapse
Affiliation(s)
- Richard G Bachur
- Division of Emergency Medicine, Boston Children's Hospital and Harvard Medical School, Boston, MA.
| | - Michael J Callahan
- Department of Radiology, Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - Michael C Monuteaux
- Division of Emergency Medicine, Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - Shawn J Rangel
- Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA
| |
Collapse
|
27
|
Journal Club: the Alvarado score as a method for reducing the number of CT studies when appendiceal ultrasound fails to visualize the appendix in adults. AJR Am J Roentgenol 2015; 204:519-26. [PMID: 25714280 DOI: 10.2214/ajr.14.12864] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE. The purpose of this article is to evaluate the hypothesis that Alvarado scores of 3 or lower identify adult patients who are unlikely to benefit from CT after appendiceal ultrasound fails to show the appendix and is otherwise normal. MATERIALS AND METHODS. We identified 119 consecutive adults for whom the appendix was not seen on otherwise normal appendiceal sonography performed as the first imaging study for suspected appendicitis, who subsequently underwent CT within 48 hours, and whose data permitted retrospective calculation of admission Alvarado scores. Specific benefits of CT were defined as diagnoses of appendicitis or significant alternative findings, and specific benefits were compared between patients with Alvarado scores of 3 or less and 4 or higher. Significant alternative findings on CT were findings other than appendicitis that were treated with medical or surgical therapy during the admission or that were to be addressed during follow-up care. Diagnostic reference standards were discharge diagnoses, pathologic examinations, and clinical follow-up. RESULTS. No patients (0.0%, 0/49) with Alvarado scores 3 or lower had appendicitis, compared with 17.1% (12/70) of patients with Alvarado scores 4 or higher (p = 0.001), and CT showed neither appendicitis nor significant alternative findings in 85.7% (42/49) versus 58.6% (41/70) of these patients, respectively (p = 0.002). The rates of perforated appendicitis, as well as significant alternative CT findings, did not differ significantly. CONCLUSION. Adults with Alvarado scores 3 or lower who have nonvisualized appendixes and otherwise normal appendiceal sonography are at very low risk for appendicitis or significant alternative findings and therefore are not likely to benefit from CT.
Collapse
|
28
|
Wagenaar AE, Tashiro J, Wang B, Curbelo M, Mendelson KL, Perez EA, Hogan AR, Neville HL, Sola JE. Protocol for suspected pediatric appendicitis limits computed tomography utilization. J Surg Res 2015; 199:153-8. [PMID: 25979562 DOI: 10.1016/j.jss.2015.04.028] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2015] [Revised: 03/11/2015] [Accepted: 04/09/2015] [Indexed: 01/14/2023]
Abstract
BACKGROUND Despite radiation concerns, computed tomography (CT) remains the favored imaging modality at many children's hospitals for appendicitis. We sought to reduce CT utilization for appendicitis in a children's hospital with an algorithm relying on 24-h ultrasound (US) as the primary imaging study. MATERIALS AND METHODS An US-based protocol for suspected appendicitis was adopted at the end of the fiscal year (FY) 2011. Data were collected for 12 mo before and 24 mo after implementation. Imaging test usage and charges were adjusted per annual number of appendectomies. Training of emergency department staff continued over 1 y after protocol implementation. RESULTS For FY 2011, 644 abdominal CT and 1088 appendix US were ordered, and 249 laparoscopic appendectomies (LAs) were performed. After protocol implementation, FY 2012: 535 CT, 1285 US, and 265 LA were performed; and FY 2013: 330 CT, 1235 US, and 236 LA were performed. Length of stay decreased from before to after protocol (2.57 ± 0.29 versus 2.15 ± 0.11 d), P < 0.001. CTs per appendectomy decreased 42% from FY 2011 to FY 2013 (2.43 versus 1.40, P < 0.001) and 30% from before to after protocol (2.43 versus 1.70, P < 0.001). A corresponding 27% increase in number of US before to after protocol (4.11 versus 5.20 US/appendectomy, P = 0.004) occurred. CT and US charges decreased $2253 and $6633 per appendectomy for FY 2012 and 2013, respectively. CONCLUSIONS Protocol-driven workup with US significantly reduced CT utilization, radiation exposure, and imaging-related charges in children with suspected appendicitis. Ongoing training of emergency department staff is required to ensure protocol compliance.
Collapse
Affiliation(s)
- Amy E Wagenaar
- Division of Pediatric Surgery, DeWitt-Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, Florida
| | - Jun Tashiro
- Division of Pediatric Surgery, DeWitt-Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, Florida
| | - Bo Wang
- Division of Pediatric Surgery, DeWitt-Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, Florida
| | - Miosotys Curbelo
- Department of Pediatrics, Baptist Children's Hospital, Miami, Florida
| | | | - Eduardo A Perez
- Division of Pediatric Surgery, DeWitt-Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, Florida; Department of Pediatrics, Baptist Children's Hospital, Miami, Florida
| | - Anthony R Hogan
- Division of Pediatric Surgery, DeWitt-Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, Florida; Department of Pediatrics, Baptist Children's Hospital, Miami, Florida
| | - Holly L Neville
- Division of Pediatric Surgery, DeWitt-Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, Florida; Department of Pediatrics, Baptist Children's Hospital, Miami, Florida
| | - Juan E Sola
- Division of Pediatric Surgery, DeWitt-Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, Florida; Department of Pediatrics, Baptist Children's Hospital, Miami, Florida.
| |
Collapse
|
29
|
Schuh S, Chan K, Langer JC, Kulik D, Preto-Zamperlini M, Aswad NA, Man C, Mohanta A, Stephens D, Doria AS. Properties of serial ultrasound clinical diagnostic pathway in suspected appendicitis and related computed tomography use. Acad Emerg Med 2015; 22:406-14. [PMID: 25808065 DOI: 10.1111/acem.12631] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2014] [Revised: 07/24/2014] [Accepted: 11/26/2014] [Indexed: 12/16/2022]
Abstract
OBJECTIVES The primary objective was to determine the diagnostic accuracy of a serial ultrasound (US) clinical diagnostic pathway to detect appendicitis in children presenting to the emergency department (ED). The secondary objective was to examine the diagnostic performance of the initial and interval US and to compare the accuracy of the pathway to that of the initial US. METHODS This was a prospective cohort study of 294 previously healthy children 4 to 17 years old with suspected appendicitis and baseline pediatric appendicitis scores of ≥2, who were managed with the serial US clinical diagnostic pathway. This pathway consisted of an initial US followed by a clinical reassessment in each patient and an interval US and surgical consultation in patients with equivocal initial US and persistent concern about appendicitis. The USs were interpreted by published criteria as positive, negative, or equivocal for appendicitis. Children in whom this pathway did not rule in or rule out appendicitis underwent computed tomography (CT). Cases with missed appendicitis, negative operations, and CTs after the pathway were considered inaccurate. The primary outcome was the diagnostic accuracy of the serial US clinical diagnostic pathway. The secondary outcomes included the test performance of the initial and interval US imaging studies. RESULTS Of the 294 study children, 111 (38%) had appendicitis. Using the serial US clinical diagnostic pathway, 274 of 294 children (93%, 95% confidence interval [CI] = 90% to 96%) had diagnostically accurate results: 108 of the 111 (97%) appendicitis cases were successfully identified by the pathway without CT scans (two missed and one CT), and 166 of the 183 (91%) negative cases were ruled out without CT scans (14 negative operations and three CTs). The sensitivity of this pathway was 108 of 111 (97%, 95% CI = 94% to 100%), specificity 166 of 183 (91%, 95% CI = 87% to 95%), positive predictive value 108 of 125 (86%; 95% CI = 79% to 92%), and negative predictive value 166 of 169 (98%, 95% CI = 96% to 100%). The diagnostic accuracy of the pathway was higher than that of the initial US alone (274 of 294 vs. 160 of 294; p < 0.0001). Of 123 patients with equivocal initial US, concern about appendicitis subsided on clinical reassessment in 73 (no surgery and no missed appendicitis). Of 50 children with persistent symptoms, 40 underwent interval US and 10 had surgical consultation alone. The interval US confirmed or ruled out appendicitis in 22 of 40 children (55.0%) with equivocal initial US, with one false-positive interval US. CONCLUSIONS The serial US clinical diagnostic pathway in suspected appendicitis has an acceptable diagnostic accuracy that is significantly higher than that of the initial US and results in few CT scans. This approach appears most useful in children with equivocal initial US, in whom the majority of negative cases were identified at clinical reassessment and appendicitis was diagnosed by interval US or surgical consultation in most study patients.
Collapse
Affiliation(s)
- Suzanne Schuh
- Division of Pediatric Emergency Medicine; University of Toronto; Toronto Ontario Canada
- Department of Pediatrics; University of Toronto; Toronto Ontario Canada
- Research Institute; University of Toronto; Toronto Ontario Canada
| | - Kevin Chan
- Division of Pediatric Emergency Medicine; University of Toronto; Toronto Ontario Canada
| | - Jacob C. Langer
- Department of Surgery; University of Toronto; Toronto Ontario Canada
| | - Dina Kulik
- Division of Pediatric Emergency Medicine; University of Toronto; Toronto Ontario Canada
| | | | - Nadine Al Aswad
- Division of Diagnostic Imaging; The Hospital for Sick Children; University of Toronto; Toronto Ontario Canada
| | - Carina Man
- Division of Diagnostic Imaging; The Hospital for Sick Children; University of Toronto; Toronto Ontario Canada
| | - Arun Mohanta
- Division of Diagnostic Imaging; The Hospital for Sick Children; University of Toronto; Toronto Ontario Canada
| | - Derek Stephens
- Research Institute; University of Toronto; Toronto Ontario Canada
| | - Andrea S. Doria
- Division of Diagnostic Imaging; The Hospital for Sick Children; University of Toronto; Toronto Ontario Canada
- Research Institute; University of Toronto; Toronto Ontario Canada
| |
Collapse
|
30
|
Diagnostic imaging for acute appendicitis: interfacility differences in practice patterns. Pediatr Surg Int 2015; 31:355-61. [PMID: 25700686 DOI: 10.1007/s00383-015-3669-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/20/2015] [Indexed: 01/28/2023]
Abstract
PURPOSE To evaluate trends and factors associated with interfacility differences in imaging modality selection in the diagnosis and management of children with suspected acute appendicitis. METHODS We conducted a retrospective review of diagnostic imaging selection and outcomes in patients <20 years of age who underwent appendectomy at a single Children's Hospital from June 2008 to June 2013. These results were then compared with those of referring hospitals. RESULTS A total of 232 children underwent appendectomy during the study period. Imaging results contributed to diagnostic and management decisions in 95.3 % of cases. CT scan was utilized as first-line imaging in 50 % of cases. CTs were preferentially performed at referring institutions (78 vs. 46 %, p < 0.001). Children were five times more likely to undergo CT at referring institutions (OR = 5.5, CI 3.0-10.2). Adjusting for demographics and Alvarado score, diagnostic imaging choice was independent of patient's clinical status. CONCLUSION This study demonstrates that initial presentation to a referring hospital independently predicts the use of CT scan for suspected acute appendicitis. Further efforts should be undertaken to develop a clinical pathway that minimizes radiation exposure in the diagnosis of acute appendicitis, with focus on access to pediatric abdominal ultrasound.
Collapse
|
31
|
Prospective validation of Alvarado score and Pediatric Appendicitis Score for the diagnosis of acute appendicitis in children. Pediatr Emerg Care 2015; 31:164-8. [PMID: 25706925 DOI: 10.1097/pec.0000000000000375] [Citation(s) in RCA: 74] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The purpose of this study was to compare the results of the Alvarado and Pediatric Appendicitis Score (PAS) scoring systems and to establish which one is more reliable in setting the diagnosis of acute appendicitis in children. METHODS All children operated on because of acute appendicitis from October 2011 to May 2013 were enrolled in this prospective study. Both clinical scoring systems have been compared over the same patients, and cutoff values were determined by the receiver operating characteristic curve analysis. RESULTS A total of 311 patients were included in the study, and 265 (85.2%) of them had acute appendicitis. Mean Alvarado score for patients with appendicitis was 8.2 and 6.7 for those without (P < 0.001). Mean PAS for patients with appendicitis was of 7.8 and 6.6 for those without (P < 0.001). Based on the ROC curve analysis, a cutoff value for both scoring systems was 7. In patients with acute appendicitis and Alvarado score of 7 or higher, the correct diagnosis would have been set in 236 patients (sensitivity, 89%; specificity, 59%; positive predictive value, 93.1%), whereas in patients with acute appendicitis and a PAS of 7 or higher, the correct diagnosis would have been set in 228 patients (sensitivity, 86%; specificity, 50%; positive predictive value, 90.1%). No significant difference was found in sensitivity and specificity between the observed scoring systems. CONCLUSIONS Both scoring systems can be of assistance in setting the diagnosis of acute appendicitis, but none has adequate predictive values in assessing acute appendicitis and none can be used as an exclusive standard in setting the diagnosis of acute appendicitis in children. The final decision still remaines on the opinion of an expert pediatric surgeon.
Collapse
|
32
|
Pershad J, Waters TM, Langham MR, Li T, Huang EY. Cost-effectiveness of diagnostic approaches to suspected appendicitis in children. J Am Coll Surg 2014; 220:738-46. [PMID: 25667142 DOI: 10.1016/j.jamcollsurg.2014.12.019] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2014] [Accepted: 12/15/2014] [Indexed: 11/18/2022]
Abstract
BACKGROUND Our group recently published a clinical pathway (Le Bonheur Clinical Pathway [LeB-P]) that used the Samuel Pediatric Appendicitis Score with selective use of ultrasonography (USG) for diagnosis of children at risk for appendicitis. The objective of this study was to model the cost-effectiveness of implementing the LeB-P compared with usual care. STUDY DESIGN We constructed a decision analytic model comparing hospital costs for the following diagnostic strategies for suspected appendicitis: emergency department clinician judgment alone, USG on all patients, CT on all patients, overnight observation with surgical evaluation without studies, and the LeB-P. Prevalence of disease, outcomes probabilities, and hospital and professional costs for each option were derived from published literature, national cost data, and our previous study results. Cost-effectiveness was calculated using these 3 sets of parameters. RESULTS In the base case model, USG was the preferred strategy over LeB-P and overnight observation with surgical evaluation without studies. Emergency department clinician judgment alone and CT were dominated by the other pathways, based on either lower diagnostic accuracy or increased costs. Compared with LeB-P, USG costs $337 less per patient evaluated, but increased the diagnostic error rate by 2%. Using LeB-P rather than USG would cost an institution an additional $17,206 to eliminate one misdiagnosis, which is known as the incremental cost-effectiveness ratio. CONCLUSIONS Although performing USG on all children with suspected appendicitis was determined to be the most cost-effective strategy, using the Pediatric Appendicitis Score with selective use of USG (LeB-P) improved diagnostic accuracy at a moderate increase in cost and decreased CT use.
Collapse
Affiliation(s)
- Jay Pershad
- Department of Emergency Medicine, University of Tennessee Health Science Center, Memphis, TN
| | - Teresa M Waters
- Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis, TN
| | - Max R Langham
- Department of Surgery, University of Tennessee Health Science Center, Memphis, TN
| | - Tao Li
- Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis, TN
| | - Eunice Y Huang
- Department of Surgery, University of Tennessee Health Science Center, Memphis, TN.
| |
Collapse
|
33
|
Alemayehu H, Snyder CL, St Peter SD, Ostlie DJ. Incidence and outcomes of unexpected pathology findings after appendectomy. J Pediatr Surg 2014; 49:1390-3. [PMID: 25148744 DOI: 10.1016/j.jpedsurg.2014.01.005] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2013] [Revised: 12/13/2013] [Accepted: 01/12/2014] [Indexed: 01/25/2023]
Abstract
PURPOSE Pathologic evaluation of the appendix after appendectomy is routine and can identify unexpected findings. We evaluated our experience in children undergoing appendectomy to review the clinical course of patients with unexpected appendiceal pathology. METHODS After IRB approval, a retrospective review was conducted on patients who underwent appendectomy from January 1, 1995 to March 1, 2011. Patient demographics, diagnosis, pathological findings, disease outcomes, and treatment were collected only on patients with abnormal pathology. RESULTS 3602 patients underwent appendectomy. 113 patients had normal appendices, and 86 patients had unexpected findings, including carcinoid tumor (n=9), pinworm (n=34), granuloma (n=14), eosinophilic infiltrates (n=18), and other (n=11). All cases of carcinoid tumor were completely resected, with no recurrence or need for reoperation. Of the 34 patients with pinworm infestation, 41.2% underwent antimicrobial therapy, and none had post-operative symptoms. One patient (7%) with an appendiceal granuloma developed Crohn's disease. Three patients (16.7%) with eosinophilia developed symptomatic intestinal eosinophilia. CONCLUSIONS Pediatric appendiceal carcinoid is an incidental finding; in this series, none required further intervention. Appendiceal granulomas are not commonly associated with developing Crohn's disease in the short term. Routine antibiotics for the treatment of pinworms are adequate. Patients with appendiceal eosinophilia may develop symptomatic intestinal eosinophilia.
Collapse
|
34
|
Ebell MH, Shinholser J. What are the most clinically useful cutoffs for the Alvarado and Pediatric Appendicitis Scores? A systematic review. Ann Emerg Med 2014; 64:365-372.e2. [PMID: 24731432 DOI: 10.1016/j.annemergmed.2014.02.025] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2013] [Revised: 01/25/2014] [Accepted: 02/28/2014] [Indexed: 12/13/2022]
Abstract
STUDY OBJECTIVE The objective of this study is to systematically review the accuracy of the Alvarado score and Pediatric Appendicitis Score and to identify optimal cutoffs for low- and high-risk populations. METHODS We performed a systematic review of the literature and identified 26 studies of the accuracy of the Alvarado score and Pediatric Appendicitis Score. Data were abstracted in parallel, and only prospective, cohort studies that avoided verification bias were included. We calculated summary likelihood ratios for low-, moderate-, and high-risk groups, using all possible cutoffs based on available data, even if not reported in the original study. RESULTS The pretest probability of appendicitis was approximately 33% in studies of children and approximately 66% in studies of adults. Likelihood ratios at different cutoffs for the Alvarado score in adults were as follows: 0.03 (<4 points), 0.42 (4 to 6 points), and 3.4 (≥ 7 points); and 0.01 (<5 points), 0.98 (5 to 8 points), and 6.7 (≥ 9 points). Likelihood ratios for the Alvarado score in children were as follows: 0.02 (<4 points), 0.27 (4 to 6 points), and 4.2 (≥ 7 points); and 0.04 (<5 points), 1.2 (5 to 8 points), and 8.5 (≥ 9 points). For the Pediatric Appendicitis Score, likelihood ratios were 0.13 (<4 points), 0.70 (4 to 7 points), and 8.1 (≥ 8 points). CONCLUSION For children with a pretest probability of acute appendicitis of 60% or less, an Alvarado score below 4 rules out the diagnosis; this is also true for a score less than 5 if the pretest probability is up to approximately 40%. In adults with a pretest probability greater than or equal to 60%, an Alvarado score of 8 or higher rules in the diagnosis, whereas one of 9 or higher rules in the diagnosis at pretest probabilities greater than or equal to 40%. The Pediatric Appendicitis Score did not identify clinically useful low- or high-risk groups at typical pretest probabilities.
Collapse
Affiliation(s)
- Mark H Ebell
- Department of Epidemiology and Biostatistics, College of Public Health, University of Georgia, Athens, GA.
| | - JoAnna Shinholser
- Department of Epidemiology and Biostatistics, College of Public Health, University of Georgia, Athens, GA
| |
Collapse
|
35
|
Clinical scores for prediction of acute appendicitis in children in a hospital of Lima, Perú. ANNALS OF PEDIATRIC SURGERY 2014. [DOI: 10.1097/01.xps.0000445129.75228.d8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
|
36
|
Sencan A, Aksoy N, Yıldız M, Okur Ö, Demircan Y, Karaca I. The evaluation of the validity of Alvarado, Eskelinen, Lintula and Ohmann scoring systems in diagnosing acute appendicitis in children. Pediatr Surg Int 2014; 30:317-21. [PMID: 24448910 DOI: 10.1007/s00383-014-3467-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
PURPOSE To show whether Alvarado, Eskelinen, Lintula and Ohmann scoring systems have predictive values in diagnosing acute appendicitis in children. METHODS Sixty patients with suspected acute appendicitis were prospectively evaluated. Alvarado, Eskelinen, Lintula and Ohmann scores were calculated separately for each patient at the time of admission. The specificity, sensitivity, positive and negative predictive values of the scores were calculated. The predictive value of the scores was evaluated with the receiver operating characteristic (ROC) curve and the consistency among the scores by Kappa test. RESULTS Twenty of the patients were female (33.3 %). The mean age of the patients was 9.9 years (3-16 years). Forty two patients were operated and appendectomies were performed with the diagnosis of acute appendicitis. The area under the ROC curve showed that the scores had no predictive value in diagnosing acute appendicitis. Kappa test showed that agreement between the scores was not good. CONCLUSION The sensitivity and specificity of the four scoring systems were not sufficient enough in diagnosing acute appendicitis in our patient group. We concluded that the most important factor affecting the decision for surgery in suspected acute appendicitis is the surgeon's experience combined with physical findings of repeated clinical examinations.
Collapse
Affiliation(s)
- Arzu Sencan
- Department of Pediatric Surgery, Dr. Behçet Uz Children's Trianing Hospital, Izmir, Turkey,
| | | | | | | | | | | |
Collapse
|
37
|
Saucier A, Huang EY, Emeremni CA, Pershad J. Prospective evaluation of a clinical pathway for suspected appendicitis. Pediatrics 2014; 133:e88-95. [PMID: 24379237 DOI: 10.1542/peds.2013-2208] [Citation(s) in RCA: 77] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE To evaluate the diagnostic accuracy of a clinical pathway for suspected appendicitis combining the Samuel's pediatric appendicitis score (PAS) and selective use of ultrasonography (US) as the primary imaging modality. METHODS Prospective, observational cohort study conducted at an urban, academic pediatric emergency department. After initial evaluation, patients were determined to be at low (PAS 1-3), intermediate (PAS 4-7), or high (PAS 8-10) risk for appendicitis. Low-risk patients were discharged with telephone follow-up. High-risk patients received immediate surgical consultation. Patients at intermediate risk for appendicitis underwent US. RESULTS Of the 196 patients enrolled, 65 (33.2%) had appendicitis. An initial PAS of 1-3 was noted in 44 (22.4%), 4-7 in 119 (60.7%), and 8-10 in 33 (16.9%) patients. Ultrasonography was performed in 128 (65.3%) patients, and 48 (37.5%) were positive. An abdominal computed tomography scan was requested by the surgical consultants in 13 (6.6%) patients. The negative appendectomy rate was 3 of 68 (4.4%). Follow-up was established on 190 of 196 (96.9%) patients. Overall diagnostic accuracy of the pathway was 94% (95% confidence interval [CI] 91%-97%) with a sensitivity of 92.3% (95% CI 83.0%-97.5%), specificity of 94.7% (95% CI 89.3%-97.8%), likelihood ratio (+) 17.3 (95% CI 8.4-35.6) and likelihood ratio (-) 0.08 (95% CI 0.04-0.19). CONCLUSIONS Our protocol demonstrates high sensitivity and specificity for diagnosis of appendicitis in children. Institutions should consider investing in resources that increase the availability of expertise in pediatric US. Standardization of care may decrease radiation exposure associated with use of computed tomography scans.
Collapse
Affiliation(s)
- Ashley Saucier
- Division of Emergency Medicine, Department of Pediatrics, Le Bonheur Children's Hospital, Memphis, TN 38103.
| | | | | | | |
Collapse
|
38
|
Huang TH, Huang YC, Tu CW. Acute appendicitis or not: Facts and suggestions to reduce valueless surgery. J Acute Med 2013. [DOI: 10.1016/j.jacme.2013.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
|
39
|
How do you diagnose appendicitis? An international evaluation of methods. Int J Surg 2013; 12:67-70. [PMID: 24211647 DOI: 10.1016/j.ijsu.2013.10.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2013] [Revised: 10/17/2013] [Accepted: 10/23/2013] [Indexed: 01/07/2023]
Abstract
INTRODUCTION Considerable variability exists in the diagnostic approach to acute appendicitis (in children), affecting both quality and costs of care. Interestingly, an international evaluation of what is commonly practiced today has not been performed. We aimed to document current practice patterns in the diagnosis of appendicitis in children and to determine whether a consensus exists in the workup of these patients among Canadian, Dutch, and Saudi Arabian pediatric surgeons. METHODS We performed a cross-sectional survey using a pre-designed, self-administered, 14-item survey. We sent the survey to participants via electronic mail. RESULTS In total, 83 responses were received and analyzed, yielding a response rate of 42%. The majority of respondents practiced at pediatric surgery centers with over 50 beds (58% of Canadian surgeons, 81% of Dutch surgeons, 93% of Saudi Arabian surgeons). The majority of Dutch surgeons had a preference for physical examination and radiological imaging as opposed to Canadian and Saudi Arabian surgeons who favored history and physical examination. Interestingly, only one of the surgeons surveyed used an appendicitis scoring system. Regarding history and physical examination, most respondents deemed migratory abdominal pain and localized RLQ tenderness to be most suggestive of appendicitis. Ultrasound was the most preferable imaging modality in acute appendicitis across all three countries. CONCLUSION This study demonstrates that international pediatric surgeons vary substantially in the diagnostic workup of patients with appendicitis. Furthermore, there is a variability between common practice and the current evidence. We recommend that pediatric surgeons develop clinical practice guidelines that are based on consensus information (expert opinion) and the best available literature.
Collapse
|
40
|
Deleger L, Brodzinski H, Zhai H, Li Q, Lingren T, Kirkendall ES, Alessandrini E, Solti I. Developing and evaluating an automated appendicitis risk stratification algorithm for pediatric patients in the emergency department. J Am Med Inform Assoc 2013; 20:e212-20. [PMID: 24130231 PMCID: PMC3861926 DOI: 10.1136/amiajnl-2013-001962] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To evaluate a proposed natural language processing (NLP) and machine-learning based automated method to risk stratify abdominal pain patients by analyzing the content of the electronic health record (EHR). METHODS We analyzed the EHRs of a random sample of 2100 pediatric emergency department (ED) patients with abdominal pain, including all with a final diagnosis of appendicitis. We developed an automated system to extract relevant elements from ED physician notes and lab values and to automatically assign a risk category for acute appendicitis (high, equivocal, or low), based on the Pediatric Appendicitis Score. We evaluated the performance of the system against a manually created gold standard (chart reviews by ED physicians) for recall, specificity, and precision. RESULTS The system achieved an average F-measure of 0.867 (0.869 recall and 0.863 precision) for risk classification, which was comparable to physician experts. Recall/precision were 0.897/0.952 in the low-risk category, 0.855/0.886 in the high-risk category, and 0.854/0.766 in the equivocal-risk category. The information that the system required as input to achieve high F-measure was available within the first 4 h of the ED visit. CONCLUSIONS Automated appendicitis risk categorization based on EHR content, including information from clinical notes, shows comparable performance to physician chart reviewers as measured by their inter-annotator agreement and represents a promising new approach for computerized decision support to promote application of evidence-based medicine at the point of care.
Collapse
Affiliation(s)
- Louise Deleger
- Division of Biomedical Informatics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | | | | | | | | | | | | | | |
Collapse
|
41
|
Quigley AJ, Stafrace S. Ultrasound assessment of acute appendicitis in paediatric patients: methodology and pictorial overview of findings seen. Insights Imaging 2013; 4:741-51. [PMID: 23996381 PMCID: PMC3846936 DOI: 10.1007/s13244-013-0275-3] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2013] [Revised: 07/04/2013] [Accepted: 07/10/2013] [Indexed: 12/27/2022] Open
Abstract
Acute appendicitis is a common surgical emergency in the paediatric population. Computed tomography (CT) has been shown to have high accuracy and low operator dependence in the diagnosis of appendicitis. However, with increased concerns regarding CT usage in children, ultrasound (US) is the imaging modality of choice in patients where appendicitis is suspected. This review describes and illustrates the step-wise graded-compression technique for the visualisation of the appendix, the normal and pathological appearances of the appendix, as well as the imaging characteristics of the common differentials. • A step-wise technique improves the chances of visualisation of the appendix. • There are often several causes for the non-visualisation of the appendix in children. • A pathological appendix has characteristic US signs, with several secondary features also identified. • There are multiple common differentials to consider in the paediatric patient.
Collapse
Affiliation(s)
- Alan J. Quigley
- NHS Grampian, In-Patient Radiology Department, Aberdeen Royal Infirmary, Aberdeen, AB25 2ZN UK
| | - Samuel Stafrace
- NHS Grampian, Radiology Department, Royal Aberdeen Children’s Hospital, Aberdeen, AB25 2ZG UK
| |
Collapse
|
42
|
Abstract
BACKGROUND Health information technology (HIT) systems have the potential to reduce delayed, missed or incorrect diagnoses. We describe and classify the current state of diagnostic HIT and identify future research directions. METHODS A multi-pronged literature search was conducted using PubMed, Web of Science, backwards and forwards reference searches and contributions from domain experts. We included HIT systems evaluated in clinical and experimental settings as well as previous reviews, and excluded radiology computer-aided diagnosis, monitor alerts and alarms, and studies focused on disease staging and prognosis. Articles were organised within a conceptual framework of the diagnostic process and areas requiring further investigation were identified. RESULTS HIT approaches, tools and algorithms were identified and organised into 10 categories related to those assisting: (1) information gathering; (2) information organisation and display; (3) differential diagnosis generation; (4) weighing of diagnoses; (5) generation of diagnostic plan; (6) access to diagnostic reference information; (7) facilitating follow-up; (8) screening for early detection in asymptomatic patients; (9) collaborative diagnosis; and (10) facilitating diagnostic feedback to clinicians. We found many studies characterising potential interventions, but relatively few evaluating the interventions in actual clinical settings and even fewer demonstrating clinical impact. CONCLUSIONS Diagnostic HIT research is still in its early stages with few demonstrations of measurable clinical impact. Future efforts need to focus on: (1) improving methods and criteria for measurement of the diagnostic process using electronic data; (2) better usability and interfaces in electronic health records; (3) more meaningful incorporation of evidence-based diagnostic protocols within clinical workflows; and (4) systematic feedback of diagnostic performance.
Collapse
Affiliation(s)
- Robert El-Kareh
- Division of Biomedical Informatics, UCSD, , San Diego, California, USA
| | | | | |
Collapse
|
43
|
Giordano S, Pääkkönen M, Salminen P, Grönroos JM. Elevated serum bilirubin in assessing the likelihood of perforation in acute appendicitis: a diagnostic meta-analysis. Int J Surg 2013; 11:795-800. [PMID: 23732757 DOI: 10.1016/j.ijsu.2013.05.029] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2012] [Revised: 04/17/2013] [Accepted: 05/17/2013] [Indexed: 11/29/2022]
Abstract
Hyperbilirubinemia associates with perforated acute appendicitis, but the precise test characteristics have not been determined by sufficiently powered studies. A systematic literature search of reports on hyperbilirubinemia in acute appendicitis was performed. After review and quality assessment of eight studies encompassing a total of 4974 patients the sensitivity, specificity and other measures of accuracy of hyperbilirubinemia as a predictor of perforation in acute appendicitis were pooled using a random-effects model. Summary estimates for hyperbilirubinemia (cutoff 1 mg/dl) as a predictor of perforation in acute appendicitis were as follows: sensitivity, 0.49 (95% confidence interval [CI], 0.45-0.52); specificity, 0.82 (95% CI, 0.80-0.83); positive likelihood ratio, 2.51 (95% CI, 1.58-4.00); negative likelihood ratio, 0.58 (95% CI, 0.44-0.76); diagnostic odds ratio was 4.42 (95% CI, 2.21-8.83). In summary receiving operating characteristic (SROC) analysis, the area under curve was 0.73. The presence of hyperbilirubinemia does not alone distinguish a perforation in acute appendicitis. Serum bilirubin level is of some value as a predictor of appendiceal perforation. Patients with hyperbilirubinemia combined with symptoms and signs consistent with severe acute appendicitis should be considered for early appendectomy.
Collapse
Affiliation(s)
- Salvatore Giordano
- Department of Surgery, Turku University Hospital and the University of Turku, Turku, Finland.
| | | | | | | |
Collapse
|
44
|
Does this child have appendicitis? A systematic review of clinical prediction rules for children with acute abdominal pain. J Clin Epidemiol 2013. [PMID: 23177898 DOI: 10.1016/j.jclinepi.2012.09.004] [Citation(s) in RCA: 112] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVES To systematically identify clinical prediction rules (CPRs) for children with suspected appendicitis and compare their methodological quality and performance. STUDY DESIGN AND SETTING Included studies involved children aged 0-18 years with suspected appendicitis identified through MEDLINE and EMBASE from 1950 to 2012. The quality was assessed using 17 previously published items. The performance was evaluated using the sensitivity, negative likelihood ratio, and predicted frequency of appendicitis diagnosis that would result if the rule was used. RESULTS Twelve studies fulfilled the inclusion criteria describing the derivation or validation of six unique CPRs involving 4,201 children with suspected appendicitis. Migratory pain, nausea or vomiting, and right lower quadrant tenderness were common predictors to all rules. Methodological quality varied widely. The most poorly addressed quality items were the predictor and outcome assessor blinding, predictor description, and reproducibility of predictor assessment. The most well-validated CPRs were the Pediatric Appendicitis Score (PAS) and MANTRELS (Migration, Anorexia, Nausea/vomiting, Tenderness in the right lower quadrant, Rebound pain, Elevation in temperature, Leukocytosis, Shift to the left)/Alvarado Score. Overall, the PAS validation studies outperformed the Alvarado validation studies. CONCLUSION The PAS and Alvarado scores were the most well validated but neither met the current performance benchmarks. A high quality, well validated, and consistently high-performing CPR was not identified. Further research is needed before a CPR for children with suspected appendicitis can be used in routine practice.
Collapse
|
45
|
Burcharth J, Pommergaard HC, Rosenberg J, Gögenur I. Hyperbilirubinemia as a predictor for appendiceal perforation: a systematic review. Scand J Surg 2013; 102:55-60. [PMID: 23820677 DOI: 10.1177/1457496913482248] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/03/2023]
Abstract
BACKGROUND AND AIMS Delayed or wrong diagnosis in patients with appendicitis can result in perforation and consequently increased morbidity and mortality. Serum bilirubin may be a useful marker for appendiceal perforation. The purpose of this systematic review was to evaluate studies investigating elevated serum bilirubin as a predictor for appendiceal perforation. MATERIAL AND METHODS Medline, Embase, and Cochrane databases were searched for studies evaluating elevated bilirubin in the diagnosis of perforated appendicitis. Study selection criteria included English language papers evaluating serum bilirubin as a marker of appendiceal perforation in humans. A total of 189 abstracts were screened for eligibility, of which five clinical studies were included in this study. RESULTS Bilirubin was significantly higher in patients with appendiceal perforation compared with patients with appendicitis without perforation. Elevated serum bilirubin had a sensitivity ranging from 0.38 to 0.77 and a specificity ranging from 0.70 to 0.87 in predicting appendiceal perforation. CONCLUSIONS Elevated serum bilirubin for determining the risk of perforation in appendicitis has low sensitivity but higher specificity. This measure can therefore be used as a supplement in the diagnostic process.
Collapse
Affiliation(s)
- J Burcharth
- Department of Surgery D, Herlev Hospital, University of Copenhagen, Herlev, Denmark
| | | | | | | |
Collapse
|
46
|
|
47
|
Yoldaş Ö, Tez M, Karaca T. Artificial neural networks in the diagnosis of acute appendicitis. Am J Emerg Med 2012; 30:1245-7. [DOI: 10.1016/j.ajem.2011.06.019] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2011] [Revised: 06/03/2011] [Accepted: 06/03/2011] [Indexed: 11/16/2022] Open
|
48
|
Pepper VK, Stanfill AB, Pearl RH. Diagnosis and management of pediatric appendicitis, intussusception, and Meckel diverticulum. Surg Clin North Am 2012; 92:505-26, vii. [PMID: 22595706 DOI: 10.1016/j.suc.2012.03.011] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Three of the most common causes of surgical abdominal pain in pediatric patients include appendicitis, Meckel diverticulum, and intussusception. All 3 can present with right lower quadrant pain, and can lead to significant morbidity and even mortality. Although ultrasound is the preferred method of diagnosis with appendicitis and intussusception, considerable variety exists in the modalities needed in the diagnosis of Meckel diverticulum. This article discusses the pathways to diagnosis, the modes of treatment, and the continued areas of controversy.
Collapse
Affiliation(s)
- Victoria K Pepper
- Section of Pediatric Surgery, Department of Surgery, University of Illinois College of Medicine at Peoria, Children's Hospital of Illinois, Peoria, IL, USA
| | | | | |
Collapse
|
49
|
Ohle R, O'Reilly F, O'Brien KK, Fahey T, Dimitrov BD. The Alvarado score for predicting acute appendicitis: a systematic review. BMC Med 2011; 9:139. [PMID: 22204638 PMCID: PMC3299622 DOI: 10.1186/1741-7015-9-139] [Citation(s) in RCA: 201] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2011] [Accepted: 12/28/2011] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND The Alvarado score can be used to stratify patients with symptoms of suspected appendicitis; the validity of the score in certain patient groups and at different cut points is still unclear. The aim of this study was to assess the discrimination (diagnostic accuracy) and calibration performance of the Alvarado score. METHODS A systematic search of validation studies in Medline, Embase, DARE and The Cochrane library was performed up to April 2011. We assessed the diagnostic accuracy of the score at the two cut-off points: score of 5 (1 to 4 vs. 5 to 10) and score of 7 (1 to 6 vs. 7 to 10). Calibration was analysed across low (1 to 4), intermediate (5 to 6) and high (7 to 10) risk strata. The analysis focused on three sub-groups: men, women and children. RESULTS Forty-two studies were included in the review. In terms of diagnostic accuracy, the cut-point of 5 was good at 'ruling out' admission for appendicitis (sensitivity 99% overall, 96% men, 99% woman, 99% children). At the cut-point of 7, recommended for 'ruling in' appendicitis and progression to surgery, the score performed poorly in each subgroup (specificity overall 81%, men 57%, woman 73%, children 76%). The Alvarado score is well calibrated in men across all risk strata (low RR 1.06, 95% CI 0.87 to 1.28; intermediate 1.09, 0.86 to 1.37 and high 1.02, 0.97 to 1.08). The score over-predicts the probability of appendicitis in children in the intermediate and high risk groups and in women across all risk strata. CONCLUSIONS The Alvarado score is a useful diagnostic 'rule out' score at a cut point of 5 for all patient groups. The score is well calibrated in men, inconsistent in children and over-predicts the probability of appendicitis in women across all strata of risk.
Collapse
Affiliation(s)
- Robert Ohle
- HRB Centre for Primary Care Research, Division of Population Health Sciences, Royal College of Surgeons in Ireland, 123 St. Stephen's Green, Dublin 2, Ireland
| | | | | | | | | |
Collapse
|
50
|
Zakaria O, Sultan TA, Khalil TH, Wahba T. Role of clinical judgment and tissue harmonic imaging ultrasonography in diagnosis of paediatric acute appendicitis. World J Emerg Surg 2011; 6:39. [PMID: 22087573 PMCID: PMC3285058 DOI: 10.1186/1749-7922-6-39] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2011] [Accepted: 11/16/2011] [Indexed: 02/08/2023] Open
Abstract
Background Appendicitis is the most common surgical emergency in children; yet, diagnosis of equivocal presentations continues to challenge clinicians. Aim The objective of this study was to investigate the hypothesis that the use of a modified clinical practice and harmonic ultrasonographic grading scores (MCPGS) may improve the accuracy in diagnosing acute appendicitis in the pediatric population. Patients & Methods Results The Number of appendectomies declined from 200 (75.5%) in our previous CPGS to 187 (70.6%) in the MCPGS (P > 0.05). Specificity was significantly higher when applying MCPGS (90.7%) in this study compared to 70.47% in our previous work when CPGS was applied (P < 0.01). Furthermore, the positive predictive value (PPV) was significantly higher (95.72%) than in our previous study (82.88%), (P < 0.01). Overall agreement (accuracy) of MCPGS was 96.98%. Kappa = 0.929 (P < 0.001). Negative predictive power was 100%. And the Overall agreement (accuracy) was 96.98%. Conclusions MCPGS tends to help in reduce the numbers of avoidable and unnecessary appendectomies in suspected cases of pediatric acute appendicitis that may help in saving hospital resources.
Collapse
Affiliation(s)
- Ossama Zakaria
- Division of Pediatric Surgery, Departments of Surgery, Faculty of Medicine, Suez Canal University, Ismailia, Egypt.
| | | | | | | |
Collapse
|