Incidence of Complicated Appendicitis as a Metric of Health Care Delivery

Association of complicated appendicitis with geographic and socioeconomic measures in children

BACKGROUND

Complicated appendicitis, considered a marker of delay in accessing surgical care among children, has been inconsistently associated with race, socioeconomic status, insurance type, rurality, and distance to care. This statewide assessment measured factors associated with complicated appendicitis while overcoming limitations of prior work, namely, selection bias and use of inexact socioeconomic status measures.

METHODS

Children (<18 years) undergoing appendectomy for appendicitis in Wisconsin from 2018 to 2021 were identified in the Wisconsin Hospital Association database. Patient residence and hospital locations were used to determine rurality, travel distances, and socioeconomic status as measured by Area Deprivation Index, Child Opportunity Index, Community Need Index, and county-level poverty rates. Multivariable logistic regression was used to assess factors associated with complicated appendicitis.

RESULTS

Among 5,881 children undergoing appendectomy, 1,375 (23.4%) had complicated appendicitis. Adjusting for other variables, complicated appendicitis was associated with younger age (adjusted odds ratio 0.90 per year increase); Hispanic White race/ethnicity (adjusted odds ratio 1.40-1.63); distance to the hospital where surgery was performed (adjusted odds ratio 1.16-1.17 per 10-mile increase); and very low Child Opportunity Index (adjusted odds ratio 1.29), Community Need Index (adjusted odds ratio 1.20 per 1-score increase), and county-level poverty (adjusted odds ratio 1.02 per 1% increase). Insurance type, rurality, and Area Deprivation Index were not associated with complicated appendicitis. Residential county-level complicated appendicitis rates (0.0%-50.0%) had moderate correlation to pediatric county-level poverty rates (rs=0.43).

CONCLUSION

Complicated appendicitis was associated with Child Opportunity Index, Community Need Index, and county-level poverty but not insurance type, rurality, or Area Deprivation Index. There was geographic variability in complicated appendicitis rates, with modest correlation to county-level poverty. Targeted interventions among Hispanic populations and those with travel- and socioeconomic status-related barriers to care may be beneficial in preventing complicated appendicitis among children.

Acute appendicitis in children: is preoperative hyponatremia a predictive factor of perforation/gangrene? A prospective study

PURPOSE

Distinguishing between perforated/gangrenous from uncomplicated appendicitis in children helps management. We evaluated hyponatremia as a new diagnostic marker for perforated/gangrenous appendicitis in children.

METHODS

A prospective study including all children with acute appendicitis who underwent appendectomy at our institution from May 2021 to May 2023. Medical history and clinical criteria were analyzed. All blood samples were taken upon admission including serum inflammatory markers and electrolytes. Patients were divided into two groups (Group I: uncomplicated and Group II: perforated/gangrenous), and data between both groups were compared.

RESULTS

The study included 153 patients [Group I: 111 (73%), Group II: 42 (27%)]. Mean serum sodium concentration in children with perforated/gangrenous appendicitis was significantly lower compared to children with uncomplicated appendicitis (131.8 mmol/L vs. 138.7 mmol/L; p < 0.001). The ROC curve of preoperative sodium level to differentiate between perforated/gangrenous and uncomplicated appendicitis revealed an AUC of 0.981. The cut-off-value of sodium level < 135 mmol/L identified perforated/gangrenous appendicitis with a sensitivity of 94% and a specificity of 91% (p < 0.001). Predictive factors of perforated/gangrenous appendicitis were: age less than 5 years (12% vs. 3%; p = 0.02), experiencing symptoms for more than 24 h (100% vs. 58%; p < 0.001), body temperature more than 38.5 °C (52% vs. 13%; p < 0.001), a serum sodium level less than 135 mmol/L (90% vs. 6%; p < 0.001), and a CRP serum level more than 50 mg/L (71% vs. 17%; p < 0.001).

CONCLUSIONS

Hyponatremia, upon admission, is a novel, objective biochemical marker that can identify perforated/gangrenous appendicitis in children. We advocate that the assessment of serum sodium level should be added to the diagnostic algorithm in children with suspected acute appendicitis. Surgical intervention in patients with hyponatremia should not be delayed, and non-operative management should be avoided.

Acute Appendicitis with Appendicolith and its Complication and Management: A Case Report

Acute appendicitis is a common cause of acute abdominal pain requiring urgent surgery. Despite characteristic clinical signs, diagnosis can be challenging, leading to unnecessary appendectomies. This case report focuses on a 34-year-old male with escalating right lower quadrant abdominal pain. Imaging revealed acute appendicitis with a substantial appendicolith. Surgical intervention involved a open appendectomy with possible ileocecal resection due to cecal inflamation. Surgical findings indicated successful resection, and the patient recovered without complications. While urgent appendectomy is the norm, conservative approaches are gaining traction for peri-appendiceal abscesses. Interval appendectomy post-conservative treatment is a debated strategy. Management decisions are influenced by patient factors and disease severity. Future research is needed to establish standardized treatment protocols for complicated appendicitis. The case illustrates the evolving landscape of acute appendicitis management.

An Update on Acute Appendicitis in Lebanon: Insights From a Single-Center Retrospective Study

Background Acute appendicitis is the most common surgical emergency worldwide with scarce reports about its prevalence in the Middle East. To date, no epidemiological article has described the incidence of appendicitis in Lebanon. Our primary objective was to estimate the rate of appendicitis in a single center in Lebanon. Our secondary objectives included identifying differences between simple and complicated appendicitis regarding demographics, pre and postoperative characteristics, and symptoms and signs of appendicitis. Methodology A retrospective study was conducted at a single central university hospital in Lebanon. Patients with a clear diagnosis of acute appendicitis were included. Pregnant women, lactating women, patients with organ dysfunction, and patients younger than 18 years old or older than 80 years old were excluded. We reviewed and collected the data of patients who presented to the hospital between November 2018 and November 2019 and November 2020 and November 2021. Results A total of 95 patients were included in our study, with 35 women and 60 men. The mean body mass index of patients with simple appendicitis was 19.14 ± 9.66 kg/m² compared to 18.97 ± 10.37 kg/m² in patients with complicated appendicitis (p = 0.94). A total of 42.3% of patients who used antibiotics 24 hours after the operation had simple appendicitis, whereas 20.8% had complicated appendicitis (p = 0.004). Conclusions Antibiotic usage and the length of hospital stay were correlated with the severity of appendicitis, as reported in the literature. Further randomized studies with a larger number of patients and covering several hospitals in Lebanon are warranted.

Hyponatremia-A New Diagnostic Marker for Complicated Acute Appendicitis in Children: A Systematic Review and Meta-Analysis

Background: Acute appendicitis in the pediatric population remains a diagnostic challenge for clinicians. Despite many biochemical markers, imaging modalities and scoring systems, initial misdiagnosis and complication rates are high in children. This suggests the need for investigations directed towards new diagnostic tools to aid in the diagnosis. Recent studies have shown a correlation between serum sodium levels and complicated appendicitis. Although the exact reasons for hyponatremia in patients with complicated appendicitis are not known, there is persuasive data to support the role of pro-inflammatory cytokines such as IL-6 in the non-osmotic release of antidiuretic hormone. This meta-analysis aims to investigate all available data on hyponatremia as a diagnostic marker of complicated appendicitis in the pediatric population. Methods: The literature search was conducted by two independent investigators according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The scientific databases (PubMed, EMBASE, Web of Science, and Scopus) were systematically searched for relevant studies using the keywords (hyponatremia) AND (appendicitis) AND (children). The methodological quality was assessed using a validated scale, and RevMan 5.4 software was utilized for pooled analysis. Results: Seven studies were included in the final meta-analysis, five of which were retrospective. A total of 1615 and 2808 cases were distributed into two groups: group A with complicated appendicitis and group B with uncomplicated acute appendicitis, respectively. The studies compared serum sodium levels of patients among the groups. Pooling the data demonstrated significantly lower serum sodium levels in children with complicated appendicitis vs. the non-complicated appendicitis (WMD: −3.29, 95% CI = −4.52 to −2.07, p < 0.00001). The estimated heterogeneity among the included studies was substantial and statistically significant (I2 = 98%, p < 0.00001). Conclusion: The results of the present meta-analysis indicate that hyponatremia has potential to be utilized as a biochemical marker in the diagnosis of complicated appendicitis in the pediatric population. However, well designed prospective diagnostic efficiency studies are essential to consolidate the association between hyponatremia and complicated acute appendicitis.