Acute appendicitis in children

Neutrophil gelatinase-associated lipocal in protein levels as an acute appendicitis biomarker in children

OBJECTIVE

Appendicitis is very commonly encountered in emergency clinics. There is an urgent need for early and accurate predictive biomarkers of appendicitis in order to save lives, because currently-available biomarkers are imprecise and their delayed response impairs the ability of emergency doctors and pediatric surgeons to provide timely and potentially effective therapies. This study was performed to determine whether changes in the blood levels of neutrophil gelatinase-associated lipocalin (NGAL) can help to diagnose acute appendicitis in children and distinguish acute appendicitis from abdominal pain.

METHODS

Sixty children were enrolled and divided into three groups, with 20 patients per group: Group 1 (patients with appendicitis), Group 2 (patients with abdominal pain) and Group 3 (control). Blood NGAL levels were determined by ELISA.

RESULTS

The basal average serum NGAL levels were 8.2 ng/ml for Group 1, 3.9 ng/ml for Group 2, and 3.3 ng/ml for Group 3. Twenty-four and 72 h after surgery the levels were 5.1 and 2.8 ng/ml, respectively, in Group 1, 2.9 and 2.8 ng/ml in Group 2, and 2.6, 2.7 ng/ml in Group 3. Setting the cut-off point to 7 generated an area under the receiving operating curve (ROC) curve at 95 % confidence interval with 77.3 % sensitivity and 97.4 % specificity.

CONCLUSION

These data indicate a significant difference in NGAL values between basal and postoperative measurements in appendicitis patients (p < 0.05). The ROC curve results showed that NGAL is a promising novel biomarker for the differential diagnosis of acute appendicitis from abdominal pain.

Delay to surgery does not influence the pathological outcome of acute appendicitis

INTRODUCTION

Emergency surgery is performed on patients with appendicitis in the belief that inflammation of the appendix may progress to necrosis and perforation. Many cases of appendicitis, however, resolve with conservative treatment, and necrotic appendicitis may represent a different disease rather than the end result of inflammation of the appendix. We wished to explore the relationship between the interval to surgery after admission to hospital with appendicitis and the proportion of patients developing necrosis.

METHODS

Appendicectomy operations performed between 2005 and 2010 were reviewed. End points included age, sex, interval from admission to surgery, and final pathological diagnosis.

RESULTS

A total of 2403 evaluable patients were identified (1266 females). Necrotic appendicitis occurred more commonly in children (17.5%) and the elderly (25.4%) compared with adults (10.5%). The median interval to surgery of patients with normal histology (17.1 h) was longer than the time to removal of inflamed (13 h) or necrotic (13.5 h) appendices (p < 0.001).The ratio of necrotic to inflamed appendicitis in the entire cohort was 0.24. Multivariate analysis reveals that necrosis of the appendix is more common in children and the elderly and that the proportion of patients with necrosis does not change with increasing interval to surgery.

DISCUSSION

Our observations show that appendicitis is not more likely to lead to perforation if a short delay prior to surgery is allowed. In addition, our findings add weight to the increasing volume of data showing that necrosis of the appendix is a disease different from simple inflammation.

Minimum postoperative antibiotic duration in advanced appendicitis in children: a review

The suitable duration of antibiotic use following appendectomy for advanced appendicitis in children is still debated. A systematic review was performed, including published experimental and observational data of antibiotic use in children who had undergone appendectomy for advanced appendicitis. Data were extracted and analyzed according to predefined criteria. Twenty-eight studies were selected that included 2,284 patients. There was no consistency among the protocols regarding length of antibiotic use, discharge criteria, or use of home antibiotics following discharge. Limiting duration of antibiotic use to 3 days did not appear to be associated with higher rates of intraabdominal abscess or wound infection. In the absence of higher-level evidence, shortening of antibiotic regimens following surgery for pediatric complicated appendicitis appears to be safe.

Weekend operating room on call staffing requirements

This article describes a statistical method used to determine the minimum number of OR teams that should be on call for urgent procedures, in-house versus on standby from home, to minimize labor costs. The OR manager obtains the number of ORs staffed at each hour of the 24-hour period of interest (e.g., 7 AM Saturday to 7 AM Sunday) from the surgical suite's information system. The minimum number of total staffed hours needed to care for patients is calculated for a prespecified level of the acceptable risk of inadequate staffing. A method used to determine whether each staff member should work in-house or on standby from home then is introduced. This method enumerates all possible combinations of shifts to find the one with the lowest cost, and it ensures a prespecified service level. An example based on 248 weeks of data collected from a large surgical suite is presented, and staffing for emergency procedures is reviewed.

Acute appendicitis in children: emergency department diagnosis and management

Early diagnosis of appendicitis in infants and children can prevent perforation, abscess formation, and postoperative complications, and can decrease cost by shortening hospitalizations. This article reviews the epidemiology, physiology, and age-specific clinical presentation of childhood appendicitis. The accuracy of diagnostic adjuncts is reviewed, as are strategies for avoiding misdiagnosis and improving emergency department evaluation and management.

Optimal sequencing of urgent surgical cases. Scheduling cases using operating room information systems

Optimal sequencing of urgent cases (i.e., selecting which urgent case should be performed first and which second) may enhance patient safety, increase patient satisfaction with timeliness of surgery, and minimize surgeons' complaints. Before determining the optimal sequence of urgent cases, an operating room (OR) suite must identify the primary scheduling objective to be satisfied when prioritizing pending urgent cases. These scheduling objectives may include: 1) perform the cases in the sequence that minimizes the average length of time each surgeon and patient waits; 2) perform the cases in the order that they were submitted; or 3) perform the cases based on medical priority, as prioritized by an OR director, or surgeons discussing the cases among themselves. We provide mathematical structure which can be used to program a computerized surgical services information system to assist in optimizing the sequence of urgent cases. We use an example to illustrate that the optimal sequence varies depending on the scheduling objective chosen.

Preoperative administration of antibiotics in patients with suspected acute appendicitis

The effectiveness of administering antibiotics preoperatively to patients with suspected appendicitis was evaluated over a 2-year period in 105 consecutive patients who presented with right lower quadrant (RLQ) tenderness and a white blood cell (WBC) count of over 10,000/mm3 or a temperature of over 37 degrees C. All the patients were preoperatively administered cefazolin (CEZ), cefotiam (CTM), or fosfomycin (FOM) except those with apparent peritonitis, which resulted in the recovery of 41 patients (39%). Of the remaining 64 patients, 14 (13%) had catarrhal appendicitis, 34 (32%), phlegmonous appendicitis, and 16 (15%), gangrenous appendicitis. Preoperatively, there were no significant differences among these groups in the WBC count or temperature. Following the administration of antibiotics, both these parameters decreased significantly in the patients with catarrhal appendicitis, although a slight RLQ tenderness persisted; in those with phlegmonous appendicitis, the WBC count decreased significantly, but the temperature remained elevated, with slight rebound tenderness in the RLQ; and in those with gangrenous appendicitis, there were no significant differences between the pre- and postoperative data in WBC count or temperature, and the abdominal symptoms did not change. These results show the value of administering antibiotics within 24h of the onset of symptoms indicative of acute appendicitis to allow time to evaluate the patients' condition, decide the operative indications, and prevent unnecessary laparotomy.

Clinical features of misdiagnosed appendicitis in children

STUDY OBJECTIVE

To compare clinical features of children with misdiagnosed appendicitis with those of children with appendicitis initially diagnosed correctly.

DESIGN

Retrospective review of hospital, emergency department, and clinic records.

SETTING

University medical center with annual ED census of 40,000 patients.

PARTICIPANTS

Children less than 13 years old admitted between May 1, 1979, and April 30, 1989, with a discharge diagnosis of appendicitis.

MEASUREMENTS

Records were reviewed for historical, physical examination, laboratory, and pathologic features for all patients on their initial presentation to a physician and on final presentation during which the correct diagnosis was made. Using chi 2 analysis and Student's test, clinical features of misdiagnosed patients and patients diagnosed correctly were compared.

RESULTS

One hundred eighty-one cases were identified with 50 initially misdiagnosed. On initial presentation, misdiagnosed patients were younger and more likely to have vomiting before pain onset, constipation, diarrhea, dysuria, and signs and symptoms of upper respiratory infections. Misdiagnosed cases were less likely to have right lower quadrant tenderness and documentation of bowel sounds, peritoneal signs, and rectal examinations. On final presentation, misdiagnosed patients were more likely to have pain duration of more than two days, temperature of more than 38.3 C, and to appear lethargic and irritable (P less than .05 for all measurements).

CONCLUSION

Clinical features of children with misdiagnosed appendicitis differ from those of children with appendicitis initially diagnosed correctly.