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Doshi N, Bandyopadhyay S, Green M, Richardson E, Komber A, Chen SE, Shah R, Lakhoo K. The Risk of Adhesive Bowel Obstruction in Children With Appendicitis: A Systematic Review. J Pediatr Surg 2024; 59:1477-1485. [PMID: 38565474 DOI: 10.1016/j.jpedsurg.2024.03.021] [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: 07/15/2023] [Revised: 02/09/2024] [Accepted: 03/09/2024] [Indexed: 04/04/2024]
Abstract
OBJECTIVE Complicated appendicitis is associated with a higher risk of postoperative complications, including adhesive bowel obstruction. The aim of this meta-analysis is to investigate the difference in rates of postoperative bowel obstruction in paediatric patients with complicated versus simple appendicitis and whether this is influenced by the surgical approach. METHODS A systematic literature search following PRISMA guidelines was conducted using MEDLINE, Embase and Cochrane Library for studies that analysed incidence of adhesive bowel obstruction in paediatric patients after appendicectomy. Studies from 1998 to 2022 were included in analysis. The study protocol was registered on PROSPERO (ID CRD42022309769). RESULTS Pooled analysis of 6 studies with low risk of bias and adequate follow up periods, considering 58,962 cases of appendicectomy, revealed complex appendicitis was associated with a near two-fold increase in incidence of SBO (pooled odds ratio 2.02 (95% CI 1.35-2.69)). Interestingly, a similar pooled analysis of 10 studies, considering 62,433 cases of appendicectomy, revealed no significant difference between open and laparoscopic management of complex appendicitis (pooled odds ratio 0.93 (95% CI 0.24 to 1.62)). CONCLUSION Complex appendicitis is associated with a two-fold increase in the rates of adhesive bowel obstruction. Whilst there are cosmetic advantages of a laparoscopic approach, surgical expertise should be favoured in decision making relating to surgical approach (laparoscopic versus open) as the evidence for a laparoscopic approach reducing risks of adhesive bowel obstruction is not convincing. LEVEL OF EVIDENCE Level II.
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Affiliation(s)
- Neel Doshi
- University of Oxford and Oxford University Hospitals, Headley Way, Headington, Oxford, OX3 9DU, United Kingdom.
| | - Soham Bandyopadhyay
- University of Oxford and Oxford University Hospitals, Headley Way, Headington, Oxford, OX3 9DU, United Kingdom
| | - Madeline Green
- University of Oxford and Oxford University Hospitals, Headley Way, Headington, Oxford, OX3 9DU, United Kingdom
| | - Edward Richardson
- University of Oxford and Oxford University Hospitals, Headley Way, Headington, Oxford, OX3 9DU, United Kingdom
| | - Ahmad Komber
- Usher Institute, University of Edinburgh, 450 Old Dalkeith Rd, Edinburgh EH16 4SS, United Kingdom
| | - Si Emma Chen
- University of Oxford and Oxford University Hospitals, Headley Way, Headington, Oxford, OX3 9DU, United Kingdom
| | - Rahul Shah
- University of Oxford and Oxford University Hospitals, Headley Way, Headington, Oxford, OX3 9DU, United Kingdom
| | - Kokila Lakhoo
- University of Oxford and Oxford University Hospitals, Headley Way, Headington, Oxford, OX3 9DU, United Kingdom
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2
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Azimi E, Fazli MR, Price N, Wahidi H. Uncomplicated appendicitis at Herat Regional Hospital: limited resource is not always the end of the world. ANZ J Surg 2024. [PMID: 39073212 DOI: 10.1111/ans.19165] [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: 08/08/2023] [Revised: 06/25/2024] [Accepted: 07/03/2024] [Indexed: 07/30/2024]
Abstract
BACKGROUND Acute appendicitis is the most common aetiology of acute abdomen in children. Our aim is to describe the accuracy of diagnosis, and complications in a limited resources setting in children between 5 and 14 years old at the only tertiary referral hospital in the West region of Afghanistan. METHODS A retrospective study for a period of 1 year (21 March 2015-20 March 2016). Data was collected from patients' files. Data were analysed by epi info 7. RESULTS We identified 774 children who had appendectomies at Herat Regional Hospital during the study period with complete records available for analysis. The median age was 11 years [5-14]. The rate of positive appendectomy was 87%. 72% of appendectomies were done within 24 h of the onset of symptoms. Of 675 positive appendectomies, the most common clinical features were migratory abdominal pain (90%), nausea/vomiting (80%), RLQ tenderness (90%), and rebound tenderness (81%). Among the 99 negative appendectomies, the most common signs and symptoms were anorexia 68%, nausea/vomiting 59%, RLQ tenderness 79%, and rebound tenderness 43%. 98% of positive and 71% of negative appendectomies had elevated WBC count. Post appendectomy complications occurred in 9% of our patients mostly commonly intra-abdominal abscesses (5%). CONCLUSION Although the diagnosis of acute appendicitis is challenging in children and may involve sophisticated imaging techniques, in many settings these are unavailable. Classical manifestations such as migratory abdominal pain, abdominal tenderness, nausea, and simple lab tests play a crucial role in the diagnosis of acute appendicitis in low resource environments.
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Affiliation(s)
- Ezmary Azimi
- Surgery Department, Herat Regional Hospital, Herat, Afghanistan
| | - Mohammad Rafi Fazli
- Surgery Department, Faculty of Medicine and Health Sciences, The University of Auckland, Auckland, New Zealand
| | - Neil Price
- Monash Children's Hospital & Monash University, Melbourne, Victoria, Australia
| | - Hania Wahidi
- Ghalib Medical Faculty, Ghalib University, Herat, Afghanistan
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Fennell J, Territo HM, Telt N, Wrotniak BH, Kozielski R, Pape E, Penque M. The Association Between C-Reactive Protein Levels and Pediatric Appendicitis Score and the Severity of Appendicitis in Children. J Emerg Med 2024; 66:e508-e515. [PMID: 38429214 DOI: 10.1016/j.jemermed.2023.11.016] [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: 05/11/2023] [Revised: 11/18/2023] [Accepted: 11/23/2023] [Indexed: 03/03/2024]
Abstract
BACKGROUND Acute appendicitis is a common cause of abdominal pain leading to emergent abdominal surgery in children. C-reactive protein (CRP), an inflammatory marker typically elevated in acute appendicitis, and Pediatric Appendicitis Score (PAS), a clinical scoring system used for the diagnosis of appendicitis, have the potential to predict the severity of inflammation of the appendix. This may be useful in helping the physician make a treatment plan prior to surgery. OBJECTIVE The purpose of this study was to assess whether CRP value and PAS differ with the extent of inflammation of the appendix seen on histologic examination. METHODS This was a prospective observational study of patients diagnosed with acute appendicitis via computed tomography or ultrasound. Enrolled patients had CRP levels drawn, PAS calculated, and appendix pathology reviewed. Appendix pathology was categorized by the pathologist on the basis of the level of inflammation: simple, suppurative, gangrenous, and perforated. RESULTS One hundred sixty-three patients were enrolled. CRP levels and PAS were statistically different (p < 0.002) among the four pathology classifications. Patients with simple appendicitis (n = 3) had a mean CRP of 2.95 mg/L and PAS of 3.9, patients with suppurative appendicitis (n = 99) had a mean CRP of 26.89 mg/L and PAS of 6.5, patients with gangrenous appendicitis (n = 56) had a mean CRP of 91.11 mg/L and PAS of 7.5, and patients with perforated appendicitis (n = 6) had a mean CRP of 154.17 mg/L and PAS of 7. The results remained statistically significant (p < 0.002) after adjusting for age, race, and sex. When combined-PAS ≥ 8 and CRP level > 40 mg/L-the specificity of complicated appendicitis was 91.2% and positive predictive value was 72.7%. CONCLUSIONS Higher CRP levels and PAS were associated with increased histologic inflammation of the appendix. This study provides preliminary evidence that CRP and PAS could potentially assist in treatment decisions for appendicitis.
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Affiliation(s)
- Jill Fennell
- Department of Pediatrics, Division of Pediatric Emergency Medicine, UBMD Pediatrics, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, John R. Oishei Children's Hospital, Buffalo, New York
| | - Heather M Territo
- Department of Pediatrics, Division of Pediatric Emergency Medicine, UBMD Pediatrics, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, John R. Oishei Children's Hospital, Buffalo, New York
| | - Nadya Telt
- Department of Pediatrics, Division of Pediatric Emergency Medicine, UBMD Pediatrics, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, John R. Oishei Children's Hospital, Buffalo, New York
| | - Brian H Wrotniak
- Department of Pediatrics, Division of Pediatric Emergency Medicine, UBMD Pediatrics, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, John R. Oishei Children's Hospital, Buffalo, New York; Masters of Public Health Program, D'Youville College, Buffalo, New York
| | - Rafal Kozielski
- Department of Pathology and Anatomical Sciences, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, John R. Oishei Children's Hospital, Buffalo, New York
| | - Earl Pape
- Department of Pathology and Anatomical Sciences, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, John R. Oishei Children's Hospital, Buffalo, New York
| | - Michelle Penque
- Department of Pediatrics, Division of Pediatric Emergency Medicine, UBMD Pediatrics, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, John R. Oishei Children's Hospital, Buffalo, New York
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Ray S, Gupta UK, Prakash G, Kumar S. Clinicopathological Profile of Appendicular Disease in Children: A Tertiary Health Care Center Study. Cureus 2023; 15:e44697. [PMID: 37809131 PMCID: PMC10551768 DOI: 10.7759/cureus.44697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/04/2023] [Indexed: 10/10/2023] Open
Abstract
Background Acute appendicitis (AA) is the most common surgical emergency worldwide. Delay in diagnosis of disease often leads to serious complications such as perforation appendicitis (PA) and gangrenous appendicitis (GA). Aims and objectives The purpose of the study is to document clinicopathological outcomes in pediatric age group patients in a tertiary health care center. Material and method This study was a prospective observation study of 50 patients with pediatric appendicitis who had undergone emergency appendectomy from January 2022 to December 2022. All pediatric patients below 15 years of age with a diagnosis of AA were included. Institute ethical permission was granted before the study, and parent consent was taken for the surgery and also for inclusion in the study. After proper resuscitation, all patients underwent appendectomy, and necessary specimens were sent for histological examination. Based on histopathology reports, all patients were classified into four groups: AA, PA, GA, and normal appendix (NA). Results Out of 50 patients, 33 (66%) patients were males and 17 (34%) patients were females. The mean age of the patients was 10.22 ± 2.73 years. The mean age of AA, PA, GA, and NA patients were 10.25 ± 2.6 years, 9.78 ± 2.99 years, 10.00 ± 4.6 years, and 12.00 ± 2.8 years, respectively. The mean duration of symptoms at the time of hospital admission was 2.42 ± 0.97 days for histopathologically proven AA patients, 4.67 ± 2.1 days for GA patients, 2.8 ± 0.83 for PA patients, and one day for NA patients. Overall clinical presentation was right iliac fossa (RIF) pain in 36 (72%) patients, migration of pain in 31 (62%) patients, anorexia in 37 (74%) patients, nausea and vomiting in 43 (86%) patients fever in 26 (52%) patients, RIF tenderness in 50 (100%) patients, rebound tenderness in 39 (78%) patients, guarding in 19 (38%) patients, Psoas's sign in nine (18% patients), and Rovsing's sign in 19 (38%) patients. On histopathological examination of the sent specimen, AA was found in 36 (72%) patients, PA was found in nine (18%) patients, GA was found in three (6%) patients, and NA was found in two (4%) patients. Wound infection was the most common complication and was found in five (10%) patients. The average duration of hospital stay for AA, PA, GA, and NA was 4.33 ± 1.04 days, 9.56 ± 4.2 days, 12.33 ± 8.5 days, and 3.50 ± 0.71 days, respectively. Conclusion The appendicular disease is common in teenage male children. Fever, dehydration, and rebound tenderness at the RIF are clinically significant findings. Duration of symptoms at the time of diagnosis, post-appendectomy complication, and duration of hospital stay significantly correlated with histopathological findings.
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Affiliation(s)
- Saugata Ray
- Department of Surgery, Midnapore Medical College and Hospital, Midnapore, IND
| | - Umesh K Gupta
- Department of Pediatric Surgery, Uttar Pradesh University of Medical Sciences, Etawah, IND
| | - Gautam Prakash
- Department of Pediatric Surgery, Indira Gandhi Institute of Medical Sciences, Patna, IND
| | - Shesh Kumar
- Department of General Surgery, Uttar Pradesh University of Medical Sciences, Etawah, IND
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Muacevic A, Adler JR, Hakeem H, Othman A, Halawani M, Tashkandi A. The Use of Inflammatory Markers to Rule Out Acute Appendicitis in Pediatrics. Cureus 2022; 14:e31374. [PMID: 36514558 PMCID: PMC9741917 DOI: 10.7759/cureus.31374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/11/2022] [Indexed: 11/13/2022] Open
Abstract
Background Acute appendicitis is the most common abdominal surgical emergency in pediatric patients. The diagnosis of acute appendicitis in pediatrics is challenging and requires an accurate physical examination, laboratory study, and imaging. The aim of this study was to determine the benefits of using three inflammatory markers, white blood count (WBC), neutrophils percent (NE%), and C-reactive protein (CRP), in ruling out appendicitis in pediatric patients. Methods A retrospective study was conducted of 152 pediatric patients aged between 6 months and 14 years presenting to the emergency department between January 2018 and December 2020, with the diagnosis of appendicitis as the primary physician's main diagnosis. Demographic information and clinical data were extracted from the medical file for each patient. Results Out of the 152 patients included, 68 (44.7%) were female and 84 (55.3%) were male, with median age was 8.1 years. Thirty-six (23.7%) had acute appendicitis confirmed by histopathology. Of these 36 patients, only two patients (5.6%) had all inflammatory markers within normal limits. Conclusion Although raised inflammatory markers may help diagnose acute appendicitis, their role in ruling it out remains limited.
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Zhou J, Xu W, Wang J, Fan Z. Related Markers for the Precision Diagnosis of Complex Appendicitis in Children. Front Pharmacol 2022; 13:865303. [PMID: 35431963 PMCID: PMC9010144 DOI: 10.3389/fphar.2022.865303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Accepted: 03/03/2022] [Indexed: 11/13/2022] Open
Abstract
Acute appendicitis is the most common surgical emergency in children. Despite the high incidence rate of appendicitis, it is sometimes misdiagnosed or missed. Complex appendicitis (CA) in children is characterized by a critical condition, several complications, and high mortality. Precision distinguishing between simple appendicitis and CA correctly is key to choosing appropriate treatment. A safe, cheap, rapid, extensive and accurate diagnostic marker of appendicitis will be of great significance for emergency general surgeons to treat suspected CA. Many studies have investigated possible diagnostic markers for the diagnosis of CA in children. In this study, studies related to CA in children in recent years are summarized, and the related markers and scoring system for the diagnosis of CA in children are summarized.
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Affiliation(s)
- Jialin Zhou
- Department of General Surgery, The Third People’s Hospital of Dalian, Dalian Medical University, Dalian, China
- Department of Central Laboratory, The Third People’s Hospital of Dalian, Dalian Medical University, Dalian, China
| | - Wenjing Xu
- Department of General Surgery, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Jitao Wang
- Department of Hepatobiliary Surgery, Xingtai People’s Hospital, Xingtai, China
- *Correspondence: Jitao Wang, ; Zhe Fan,
| | - Zhe Fan
- Department of General Surgery, The Third People’s Hospital of Dalian, Dalian Medical University, Dalian, China
- Department of Central Laboratory, The Third People’s Hospital of Dalian, Dalian Medical University, Dalian, China
- *Correspondence: Jitao Wang, ; Zhe Fan,
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7
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Dooki ME, Nezhadan M, Mehrabani S, Osia S, Hadipoor A, Hajiahmadi M, Mohammadi M. Diagnostic accuracy of laboratory markers for diagnosis of acute appendicitis in children. Wien Med Wochenschr 2022; 172:303-307. [PMID: 35006517 DOI: 10.1007/s10354-021-00898-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Accepted: 11/22/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Acute appendicitis (AA), the most common abdominal emergency disease, is one of the most important causes of hospitalization of children. Studies have shown that white blood cell (WBC) count, mean platelet volume (MPV), C‑reactive protein (CRP), and erythrocyte sedimentation rate (ESR) can play an important role in the diagnostic prediction of appendicitis. Therefore, the aim of this study was to evaluate the diagnostic value of WBC count, polymorphonuclear leukocytes (PMNs) percentage, MPV, CRP, and ESR for the diagnosis of AA. METHODS In this study, 100 medical records were reviewed for children referred to the hospital complaining of abdominal pain and who underwent operation with a provisional diagnosis of acute appendicitis based on clinical and laboratory findings. Patients were divided into two groups according to the pathology gold standard method: AA and the other group with acute abdominal pain without appendicitis (AAP). The diagnostic accuracy of WBC, PMNs%, MPV, ESR, and CRP were compared for patients with AA and AAP. RESULTS A total of 100 patients (50 with AA and 50 with AAP) were identified. The sensitivity and specificity of WBC and PMNs% were 78 and 66%, and 76 and 54%, respectively; ESR was 80 and 48%, respectively; and CRP was 82 and 62% (30-89%), respectively. A low specificity (8%) and 70% sensitivity was calculated using the cutoff point of 8.1 fl for MPV. CONCLUSION Our data suggest that children with AA often present with significantly higher WBC count, ESR level, CRP level, PMNs%, and lower MPV level. The results of the study showed that WBC, CRP, and ESR, along with other diagnostic methods, can be useful in diagnosing AA in children. MPV is not effective in the diagnosis of AA due to its specificity; however, a significantly lower level was found in children with AA.
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Affiliation(s)
- Mohammadreza Esmaeili Dooki
- Non-Communicable Pediatric Disease Research Center, Health Research Institute, Babol University of Medical Sciences, Babol, Iran
| | - Masoud Nezhadan
- Non-Communicable Pediatric Disease Research Center, Health Research Institute, Babol University of Medical Sciences, Babol, Iran
| | - Sanaz Mehrabani
- Non-Communicable Pediatric Disease Research Center, Health Research Institute, Babol University of Medical Sciences, Babol, Iran
| | - Soheil Osia
- The Clinical Research Development Unit of Amirkola Children's Hospital, Babol University of Medical Sciences, Babol, Iran
| | - Abbas Hadipoor
- Non-Communicable Pediatric Disease Research Center, Health Research Institute, Babol University of Medical Sciences, Babol, Iran
| | - Mahmoud Hajiahmadi
- Non-Communicable Pediatric Disease Research Center, Health Research Institute, Babol University of Medical Sciences, Babol, Iran
| | - Mohsen Mohammadi
- Non-Communicable Pediatric Disease Research Center, Health Research Institute, Babol University of Medical Sciences, Babol, Iran.
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8
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Seçilmiş Y, Sağiroğlu P, Doğan AB, Gümüştekin S, Öztürk MA. The Diagnostic Value of Presepsin in Acute Appendicitis and Reference Ranges for Healthy Children. J Trop Pediatr 2022; 68:6511399. [PMID: 35043966 DOI: 10.1093/tropej/fmac001] [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] [Indexed: 11/13/2022]
Abstract
OBJECTIVE This study aimed to investigate the diagnostic value of presepsin, a new inflammatory marker for paediatric appendicitis, and to determine a reference range of presepsin for children. METHODS This single-center prospective study was conducted in our paediatric emergency department between 1 February 2021 and 1 July 2021. Patients aged 0-18 years diagnosed with acute appendicitis, which was pathologically confirmed, and healthy volunteers in the same age group were included in the study. Serum presepsin levels were analysed using an enzyme-linked immunosorbent assay reader. In addition to presepsin, other acute-phase reactants, paediatric appendicitis scores and imaging methods were evaluated. RESULTS There were 94 patients in the acute appendicitis group and 102 healthy volunteers in the control group. Median values were compared between the two groups, and no statistically significant differences were found (p = 0.544). In addition, no statistically signivficant differences in presepsin levels were found between the acute and perforated appendicitis groups (p = 0.344). The median (IQ1-IQ3) reference range for presepsin in healthy children was 0.9950 (0.7575-1.610) ng/mL. CONCLUSION Presepsin is not a suitable marker for the diagnosis of acute appendicitis. We observed that serum presepsin levels were not elevated in paediatric appendicitis, which is a local infection, in contrast to previous studies.
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Affiliation(s)
- Yilmaz Seçilmiş
- Department of Pediatrics, Division of Pediatric Emergency, Erciyes University, Faculty of Medicine, Kayseri 38039, Turkey
| | - Pinar Sağiroğlu
- Department of Microbiology, Erciyes University, Faculty of Medicine, Kayseri 38039, Turkey
| | - Ahmet Burak Doğan
- Department of Pediatric Surgery, Erciyes University, Faculty of Medicine, Kayseri 38039, Turkey
| | - Seda Gümüştekin
- Department of Pediatrics, Division of Pediatric Emergency, Erciyes University, Faculty of Medicine, Kayseri 38039, Turkey
| | - Mehmet Adnan Öztürk
- Department of Pediatrics, Division of Pediatric Emergency, Erciyes University, Faculty of Medicine, Kayseri 38039, Turkey
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9
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Bhattacharya J, Silver EJ, Blumfield E, Jan DM, Herold BC, Goldman DL. Clinical, Laboratory and Radiographic Features Associated With Prolonged Hospitalization in Children With Complicated Appendicitis. Front Pediatr 2022; 10:828748. [PMID: 35463908 PMCID: PMC9019112 DOI: 10.3389/fped.2022.828748] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Accepted: 02/14/2022] [Indexed: 12/26/2022] Open
Abstract
OBJECTIVE In children with appendicitis, rupture of the appendix is associated with a significant increase in morbidity. We sought to characterize the spectrum of illness in children with complicated appendicitis and to define those factors associated with a longer hospital stay. STUDY DESIGN We conducted a retrospective review of 132 children, 18 years of age or younger at a large urban teaching hospital in the Bronx, NY between October 2015 and April 2018 with an intraoperative diagnosis of perforated appendix. Clinical, laboratory and radiologic findings were reviewed, and the primary study outcome was length of stay (LOS) dichotomized at the median, which was 7 days. Statistical analyses were done to characterize morbidity and define variables predictive of longer stay. RESULTS Children in the longer LOS group experienced significantly more morbidity, including ICU stay, ileus, and need for multiple drainage procedures. A longer duration of symptoms prior to presentation was associated with a longer stay. Multivariable logistic regression analysis indicated that the presence of abscess and presence of free fluid in the right upper quadrant (RUQ FF) on initial imaging and C-reactive protein (CRP) level >12 at admission, were independently associated with a longer stay. CONCLUSION There is considerable variation in the morbidity of complicated appendicitis. The association between longer stay and the findings of abscess and RUQ FF on initial imaging along with an elevated CRP may provide a useful tool in identifying those children at risk for worse outcomes.
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Affiliation(s)
- Jyotsna Bhattacharya
- Pediatric Infectious Disease, Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, NY, United States
| | - Ellen J Silver
- Academic General Pediatrics, Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, NY, United States
| | - Einat Blumfield
- Pediatric Radiology, Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, NY, United States
| | - Dominique M Jan
- Pediatric Surgery, Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, NY, United States
| | - Betsy C Herold
- Pediatric Infectious Disease, Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, NY, United States.,Department of Microbiology and Immunology, Albert Einstein College of Medicine, Bronx, NY, United States
| | - David L Goldman
- Pediatric Infectious Disease, Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, NY, United States.,Department of Microbiology and Immunology, Albert Einstein College of Medicine, Bronx, NY, United States
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10
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Walsh A, Lala S, Wells C, Upadhyay V. Hyponatremia an indicator of complicated appendicitis in children: Starship experience. ANZ J Surg 2021; 92:747-752. [PMID: 34927323 DOI: 10.1111/ans.17425] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 10/10/2021] [Accepted: 11/30/2021] [Indexed: 12/26/2022]
Abstract
BACKGROUND Timely preoperative recognition of children with complicated appendicitis allows for planning and effective management. The aim of this study was to evaluate hyponatremia, an objective biochemical marker, as a predictor of complicated appendicitis. METHODS A retrospective review of 1283 paediatric patients (≤15 years) who underwent acute appendicectomy from January 2016 to December 2020 (5-year period) was performed. Complicated appendicitis was defined by intraoperative findings of; macroscopic perforation, free pus, gangrene, faecal contamination or intraabdominal abscess. Comparison groups consisted of patients with complicated appendicitis, patients with uncomplicated appendicitis and patients with presumed appendicitis who went on to have no appendicitis on histology (no appendicitis group). Preoperative hyponatremia was defined as serum sodium <135 mmol/L. RESULTS Of the 1283 children; 35% (443/1283) had complicated appendicitis, 54% (690/1283) had uncomplicated appendicitis and 12% (150/1283) had no appendicitis. Rates of hyponatremia were much greater in the complicated group (31.4%; 139/443) than in the uncomplicated group (3.8%; 26/690) (p < 0.0001) or the no appendicitis group 10.7% (16/150) (p < 0.0001). The no appendicitis group had higher rates of hyponatremia than the uncomplicated group (p = 0.001), an unexpected finding. The receiver operating characteristic curve for diagnosis of complicated appendicitis versus uncomplicated appendicitis, using a cut-off serum sodium of <135 mmol/L will identify complicated appendicitis with sensitivity 31.4% and specificity of 95.7% (area under the curve of 0.76). CONCLUSION Hyponatremia is a discriminating predictor of complicated appendicitis in a paediatric population.
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Affiliation(s)
- Abby Walsh
- Paediatric Surgery Department, Starship Hospital, Auckland, New Zealand
| | - Shareena Lala
- Paediatric Surgery Department, Starship Hospital, Auckland, New Zealand
| | - Cameron Wells
- Department of Surgery, The University of Auckland, Auckland, New Zealand
| | - Vipul Upadhyay
- Paediatric Surgery Department, Starship Hospital, Auckland, New Zealand
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11
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Huang WY, Chen CY, Chang YJ, Lee EP, Wu HP. Serum Soluble CD40 Ligand in Predicting Simple Appendicitis and Complicated Appendicitis at Different Time Points in Children. Front Pediatr 2021; 9:676370. [PMID: 34178892 PMCID: PMC8219915 DOI: 10.3389/fped.2021.676370] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2021] [Accepted: 05/12/2021] [Indexed: 12/29/2022] Open
Abstract
Objectives: Appendicitis is a common abdominal emergency in children. It is difficult for clinicians to distinguish between simple appendicitis (SA), gangrenous appendicitis (GA), and ruptured appendicitis (RA) in children based on physical and current laboratory tests. Abdominal computed tomography with the disadvantage of excess radiation exposure is usually used in the emergency room for appendicitis surveys. Serum soluble CD40 ligand (sCD40L) is an inflammatory biomarker. This study aimed to use sCD40L to distinguish SA, GA, and RA. Methods: All patients aged <18 years old with suspected appendicitis were tested once for serum sCD40L within 72 h of appendicitis symptoms. We compared sCD40L levels of SA, GA, and RA individually on days 1, 2, and 3 in patients with normal appendix (NA), a total of nine subgroups. Thereafter, the diagnostic performance of sCD40L in predicting appendicitis and the receiver operating characteristic curves were carried out. Results: Of 116 patients, 42 patients had SA, 20 GA, 44 RA, and 10 NA. We found six subgroups with significant p-values of sCD40L predicting appendicitis as follows: SA on day 2, GA on days 2 and 3, and RA on days 1-3. The sensitivity and specificity of sCD40L at the best cutoff point with 178 pg/mL in these six subgroups range from 0.75 to 1.00 and 0.90, respectively. Conclusions: SCD40L is a good predictor of pediatric appendicitis. Clinicians can use sCD40L to distinguish from SA, GA, and RA in children with suspected appendicitis.
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Affiliation(s)
- Wun-Yan Huang
- Department of Pediatric Emergency Medicine, Children Hospital, China Medical University, Taichung, Taiwan.,Department of Medicine, School of Medicine, China Medical University, Taichung, Taiwan
| | - Chun-Yu Chen
- Department of Pediatric Emergency Medicine, Children Hospital, China Medical University, Taichung, Taiwan.,Department of Medicine, School of Medicine, China Medical University, Taichung, Taiwan
| | - Yu-Jun Chang
- Laboratory of Epidemiology and Biostastics, Changhua Christian Hospital, Changhua, Taiwan
| | - En-Pei Lee
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Linko Chang Gung Memorial Hospital, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Han-Ping Wu
- Department of Pediatric Emergency Medicine, Children Hospital, China Medical University, Taichung, Taiwan.,Department of Medicine, School of Medicine, China Medical University, Taichung, Taiwan.,Department of Medical Research, Children's Hospital, China Medical University, Taichung, Taiwan
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12
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Tan PH, Teng XX, Gan ZY, Tan SQ. A Study on the Clinical Factors Associated with Acute Appendicitis and Perforated Appendicitis among Children in a Secondary Medical Centre in Malaysia. Malays J Med Sci 2020; 27:139-146. [PMID: 32863753 PMCID: PMC7444837 DOI: 10.21315/mjms2020.27.4.13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 07/05/2020] [Indexed: 11/25/2022] Open
Abstract
Background Appendicitis complicated with appendiceal perforation is common among children. The delay in diagnosis of appendicitis is due to children’s varied presentations and their difficulty in communicating symptoms. We aimed to identify clinical factors that aid in predicting acute appendicitis (AA) and perforated appendicitis (PA) among children. Methods This retrospective study involved 215 children aged 12 years and below with the initial diagnosis of AA and PA. Clinical factors studied were demographics, presenting symptoms, body temperature on admission (BTOA), white cell count (WCC), absolute neutrophil count (ANC), platelet count and urinalysis. Simple and multiple logistic regressions were used to determine the odds ratio of the statistically significant clinical factors. Results: The mean age of the included children was 7.98 ± 2.37 years. The odds of AA increased by 2.177 times when the age was ≥ 8 years (P = 0.022), 2.380 times when duration of symptoms ≥ 2 days (P = 0.011), 2.447 times with right iliac fossa (RIF) pain (P = 0.007), 2.268 times when BTOA ≥ 38 °C (P = 0.020) and 2.382 times when neutrophil percentage was ≥ 76% (P = 0.045). It decreased by 0.409 times with non-RIF pain (P = 0.007). The odds of PA was increased by 4.672 times when duration of symptoms ≥ 2 days (P = 0.005), 3.611 times when BTOA ≥ 38 °C (P = 0.015) and 3.678 times when neutrophil percentage ≥ 76% (P = 0.016). There was no significant correlation between WCC and ANC with AA and PA. Conclusion Older children with longer duration of symptoms, RIF pain and higher BTOA are more likely to have appendicitis. The risk of appendiceal perforation increases with longer duration of symptoms and higher BTOA.
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Affiliation(s)
- Pheng Hian Tan
- Department of Surgery, Hospital Seberang Jaya, Seberang Jaya, Pulau Pinang, Malaysia
| | - Xiu Xin Teng
- Department of Surgery, Hospital Seberang Jaya, Seberang Jaya, Pulau Pinang, Malaysia
| | - Zhen Yao Gan
- Department of Surgery, Hospital Seberang Jaya, Seberang Jaya, Pulau Pinang, Malaysia
| | - Siew Qin Tan
- Department of Surgery, Hospital Seberang Jaya, Seberang Jaya, Pulau Pinang, Malaysia
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13
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Bessoff KE, Forrester JD. Appendicitis in Low-Resource Settings. Surg Infect (Larchmt) 2020; 21:523-532. [DOI: 10.1089/sur.2019.365] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Affiliation(s)
- Kovi E. Bessoff
- Division of General Surgery, Department of Surgery, Stanford University, Stanford, California, USA
| | - Joseph D. Forrester
- Division of General Surgery, Department of Surgery, Stanford University, Stanford, California, USA
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14
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Abstract
Introduction Very different results have been reported regarding the relationship between bilirubin and perforated appendicitis. We observed this relationship with our own studies. Methods The patients, who underwent appendectomy, were retrospectively categorized as perforated and non-perforated based on their files. Those with a total bilirubin (TB) 1.20 mg/dL or less were considered normal whereas those with a 1.21 mg/dL or higher were considered having a high. Those with a direct bilirubin (DB) 0.50 mg/dL or less were considered normal whereas those with a 0.51 mg/dL or higher were considered having a high. The patients were assessed under two groups. Perforated appendicitis (PA) and non-perforated appendicitis (NPA) were analyzed according to the TB in Group 1 and the DB in Group 2. Results Group 1 included 269 patients whose TB were measured. Of those, 218 had NPA and 51 had PA. The rate of patients with high TB among the patients with PA was 1.37 times higher than those with NPA (p ˂ 0.01). Group 2 included 258 patients whose DB values were measured. Of those, 208 had NPA and 50 had PA. The rate of patients with high TB among the patients with PA was 1.71 times higher than those with NPA (p ˂ 0.001). Conclusion In the diagnosis of PA, both TB and DB show low diagnostic values. In the diagnosis, they can only be considered as a supportive factor to other parameters. However, in the case of a differential diagnosis, we recommend using DB since it has a higher sensitivity and specificity.
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Affiliation(s)
- Murat Kanlioz
- General Surgery, Beylikdüzü Kolan Hospital, Istanbul, TUR
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15
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Laboratory Markers in the Prediction of Acute Perforated Appendicitis in Children. Emerg Med Int 2019; 2019:4608053. [PMID: 31641539 PMCID: PMC6770292 DOI: 10.1155/2019/4608053] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Revised: 08/30/2019] [Accepted: 09/05/2019] [Indexed: 01/08/2023] Open
Abstract
Objective This study aimed to explore the laboratory markers associated with perforation in children with acute appendicitis. Methods This retrospective study reviewed 1895 children (3–18 years old) with confirmed acute appendicitis from 2007 to 2017. Clinical (demographic characteristics, symptoms, and signs) and laboratory data (white blood cell count, C-reactive protein (CRP), procalcitonin, D-lactate, platelet count, bilirubin, aspartate aminotransferase, and alanine aminotransferase) were collected and compared between perforated and nonperforated groups. The logistic regression analysis was performed to identify independent risk factors. Results Of all patients, 613 children were perforated. Children with perforation had significantly longer duration of symptoms, higher white blood cell count, CRP level, and neutrophils percentage, and lower serum sodium level. Elevated white blood cell count with CRP level and elevated neutrophils percentage with CRP level were found to be associated with risk of perforation. Conclusions White blood cell count with C-reactive protein and neutrophils percentage with CRP are important markers in distinguishing perforated appendicitis from nonperforated appendicitis in pediatric subjects.
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16
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Howell EC, Dubina ED, Lee SL. Perforation risk in pediatric appendicitis: assessment and management. PEDIATRIC HEALTH MEDICINE AND THERAPEUTICS 2018; 9:135-145. [PMID: 30464677 PMCID: PMC6209076 DOI: 10.2147/phmt.s155302] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Perforated appendicitis, as defined by a visible hole in the appendix or an appendicolith free within the abdomen, carries significant morbidity in the pediatric population. Accurate diagnosis is challenging as there is no single symptom or sign that accurately predicts perforated appendicitis. Younger patients and those with increased duration of symptoms are at higher risk of perforated appendicitis. Elevated leukocytosis, bandemia, high C-reactive protein, hyponatremia, ultrasound, and CT are all useful tools in diagnosis. Distinguishing patients with perforation from those without is important given the influence of a perforation diagnosis on the management of the patient. Treatment for perforated appendicitis remains controversial as several options exist, each with its indications and merits, illustrating the complexity of this disease process. Patients may be managed non-operatively with antibiotics, with or without interval appendectomy. Patients may also undergo appendectomy early in the course of their index hospitalization. Factors known to predict failure of non-operative management include appendicolith, leukocytosis greater than 15,000 white blood cells per microliter, increased bands, and CT evidence of disease beyond the right lower quadrant. In this review, the indications and benefits of each treatment strategy will be discussed and an algorithm to guide treatment decisions will be proposed.
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Affiliation(s)
- Erin C Howell
- Department of Surgery, Harbor-UCLA Medical Center, Torrance, CA, USA,
| | - Emily D Dubina
- Department of Surgery, Harbor-UCLA Medical Center, Torrance, CA, USA,
| | - Steven L Lee
- Department of Surgery, Harbor-UCLA Medical Center, Torrance, CA, USA, .,Division of Pediatric Surgery, UCLA Mattel Children's Hospital, Los Angeles, CA, USA,
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17
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Bonadio W, Shahid S, Vardi L, Buckingham C, Kornblatt A, Free C, Homel P. A pre-operative clinical scoring system to distinguish perforation risk with pediatric appendicitis. J Pediatr Surg 2018; 53:441-445. [PMID: 28554816 DOI: 10.1016/j.jpedsurg.2017.05.017] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Revised: 05/05/2017] [Accepted: 05/16/2017] [Indexed: 12/12/2022]
Abstract
IMPORTANCE Appendicitis is a common, potentially serious pediatric disease. An important factor in determining management strategy [whether/when to perform appendectomy, duration of antibiotic therapy/hospitalization, etc.] and predicting outcome is distinguishing whether perforation is present. OBJECTIVE The objective was to determine efficacy of commonly assessed pre-operative variables in stratifying perforation risk in children with appendicitis. DESIGN A retrospective analysis of consecutive cases was performed. SETTING The setting was a large urban hospital pediatric emergency department. PARTICIPANTS Four hundred forty-eight consecutive cases of CT [computerized tomography]-confirmed pediatric appendicitis during a 6-year period in an urban pediatric ED [emergency department]: 162 with perforation and 286 non-perforated. MAIN OUTCOME(S) AND MEASURE(S) To determine efficacy of clinical and laboratory variables with distinguishing perforation outcome in children with appendicitis. RESULTS Regression analysis identified 3 independently significant variables associated with perforation outcome - and determined their ideal threshold values: duration of symptoms>1day; ED-measured fever [body temperature >38.0 °C]; CBC WBC absolute neutrophil count >13,000/mm3. The resulting multivariate ROC [receiver operating characteristic] curve after applying these threshold values gave an AUC [area under curve] of 89% for perforation outcome [p<0.001]. Risk for perforation was additive with each additional predictive variable exceeding its threshold value, linearly increasing from 7% with no variable present to 85% when all 3 variables are present. CONCLUSIONS A pre-operative scoring system comprised of 3 commonly assessed clinical/laboratory variables is useful in stratifying perforation risk in children with appendicitis. Physicians can utilize these factors to gauge pre-operative risk for perforation in children with appendicitis, which can potentially aid in planning subsequent management strategy. LEVEL OF EVIDENCE III.
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Affiliation(s)
- William Bonadio
- Pediatric Emergency Medicine, Maimonides Medical Center, Brooklyn, NY.
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18
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Scott A, Lee SL, DeUgarte DA, Shew SB, Dunn JCY, Shekherdimian S. Nonoperative Management of Appendicitis. Clin Pediatr (Phila) 2018; 57:200-204. [PMID: 28952357 DOI: 10.1177/0009922817696465] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
We evaluated the outcomes for nonoperative management (NOM) of all children with suspected nonperforated appendicitis, including those patients with an appendicolith. Parents of all children with suspected nonperforated appendicitis were offered NOM versus laparoscopic appendectomy. NOM included administration of intravenous antibiotics and hospital admission. If no improvement within 24 hours, laparoscopic appendectomy was performed. Primary outcomes were initial success rate and recurrence rate. Fifty patients selected NOM. The initial failure rate for NOM was 20%. Of the 10 who failed, 7 had complicated appendicitis. The recurrence rate was 13%. Overall, 34 (68%) patients avoided appendectomy. Patients with an appendicolith had a higher initial failure rate (37%) compared to patients without an appendicolith (10%; P < .05). NOM is feasible and effective in pediatric nonperforated appendicitis. The presence of an appendicolith was associated with a higher failure rate but is not an absolute contraindication for NOM.
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Affiliation(s)
- Andrew Scott
- 1 University of California at Los Angeles, CA, USA
| | - Steven L Lee
- 1 University of California at Los Angeles, CA, USA.,2 Harbor-UCLA Medical Center, Torrance, CA, USA
| | - Daniel A DeUgarte
- 1 University of California at Los Angeles, CA, USA.,2 Harbor-UCLA Medical Center, Torrance, CA, USA
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19
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Affiliation(s)
- Yangyang R Yu
- Division of Pediatric Surgery, Michael E. DeBakey Department of Surgery, Texas Children's Hospital, Baylor College of Medicine, 6701 Fannin Street, Suite 1210, Houston, TX 77030, USA
| | - Sohail R Shah
- Division of Pediatric Surgery, Michael E. DeBakey Department of Surgery, Texas Children's Hospital, Baylor College of Medicine, 6701 Fannin Street, Suite 1210, Houston, TX 77030, USA.
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20
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Affiliation(s)
- Rebecca M Rentea
- Deparment of Surgery, Children's Mercy Hospital, 2401 Gillham Road, Kansas City, MO 64108, USA
| | - Shawn D St Peter
- Pediatric Surgical Fellowship and Scholars Programs, Department of Surgery, Children's Mercy Hospital, 2401 Gillham Road, Kansas City, MO 64108, USA.
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21
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Zouari M, Abid I, Sallami S, Guitouni A, Ben Dhaou M, Jallouli M, Mhiri R. Predictive factors of complicated appendicitis in children. Am J Emerg Med 2017; 35:1982-1983. [PMID: 28668176 DOI: 10.1016/j.ajem.2017.06.049] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2017] [Accepted: 06/23/2017] [Indexed: 11/15/2022] Open
Affiliation(s)
- M Zouari
- Department of Pediatric Surgery, Hedi-Chaker Hospital, 3029 Sfax, Tunisia.
| | - I Abid
- Department of Pediatric Surgery, Hedi-Chaker Hospital, 3029 Sfax, Tunisia
| | - S Sallami
- Department of Pediatric Surgery, Hedi-Chaker Hospital, 3029 Sfax, Tunisia
| | - A Guitouni
- Department of Pediatric Surgery, Hedi-Chaker Hospital, 3029 Sfax, Tunisia
| | - M Ben Dhaou
- Department of Pediatric Surgery, Hedi-Chaker Hospital, 3029 Sfax, Tunisia
| | - M Jallouli
- Department of Pediatric Surgery, Hedi-Chaker Hospital, 3029 Sfax, Tunisia
| | - R Mhiri
- Department of Pediatric Surgery, Hedi-Chaker Hospital, 3029 Sfax, Tunisia
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22
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Malik MU, Connelly TM, Awan F, Pretorius F, Fiuza-Castineira C, El Faedy O, Balfe P. The RIPASA score is sensitive and specific for the diagnosis of acute appendicitis in a western population. Int J Colorectal Dis 2017; 32:491-497. [PMID: 27981378 DOI: 10.1007/s00384-016-2713-4] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/18/2016] [Indexed: 02/04/2023]
Abstract
AIM The definitive diagnosis of acute appendicitis (AA) requires histopathological examination. Various clinical diagnostic scoring systems attempt to reduce negative appendectomy rates. The most commonly used in Western Europe and the USA is the Alvarado score. The Raja Isteri Pengiran Anak Saleha appendicitis (RIPASA) score achieves better sensitivity and specificity in Asian and Middle Eastern populations. We aimed to determine the diagnostic accuracy of the RIPASA score in Irish patients with AA. METHODS All patients who presented to our institution with right iliac fossa pain and clinically suspected AA between January 1 and December 31, 2015, were indentified from our hospital inpatient enquiry database and retrospectively studied. Operating theatre records and histology reports confirmed those who underwent a non-elective operative procedure and the presence or absence of AA. SPSS version 22 was used for statistical analysis. Standard deviation is provided where appropriate. RESULTS Two hundred eight patients were included in the study (106/51% male, mean age 22.7 ± 9.2 years). One hundred thirty-five (64.9%) had histologically confirmed AA (mean symptom duration = 36.19 ± 15.90 h). At a score ≥7.5, the previously determined score most likely associated with AA in Eastern populations, the RIPASA scoring system demonstrated a sensitivity of 85.39%, specificity of 69.86%, positive predictive value of 84.06%, negative predictive value of 72.86% and diagnostic accuracy of 80% in our cohort. CONCLUSION The RIPASA score is a useful tool to aid in the diagnosis of acute appendicitis in the Irish population. A score of ≥7.5 provides sensitivity and specificity exceeding that previously documented for the Alvarado score in Western populations. WHAT DOES THIS PAPER ADD TO THE LITERATURE?: This is the first study evaluating the utility of the RIPASA score in predicting acute appendicitis in a Western population. At a value of 7.5, a cut-off score suggestive of appendicitis in the Eastern population, RIPASA demonstrated a high-sensitivity, specificity, positive predictive value and diagnostic accuracy in our cohort and was more accurate than the commonly used Alvarado score.
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Affiliation(s)
| | - Tara M Connelly
- Department of Surgery, University Hospital Waterford, Waterford, Ireland.
| | - Faisal Awan
- Department of Surgery, St. Luke's Hospital, Kilkenny, Ireland
| | | | | | - Osama El Faedy
- Department of Surgery, St. Luke's Hospital, Kilkenny, Ireland
| | - Paul Balfe
- Department of Surgery, St. Luke's Hospital, Kilkenny, Ireland
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23
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Abstract
Appendicitis is a common cause of abdominal pain in children. The diagnosis and treatment of the disease have undergone major changes in the past two decades, primarily as a result of the application of an evidence-based approach. Data from several randomized controlled trials, large database studies, and meta-analyses have fundamentally affected patient care. The best diagnostic approach is a standardized clinical pathway with a scoring system and selective imaging. Non-operative management of simple appendicitis is a reasonable option in selected cases, with the caveat that data in children remain limited. A minimally invasive (laparoscopic) appendectomy is the current standard in US and European children's hospitals. This article reviews the current 'state of the art' in the evaluation and management of pediatric appendicitis.
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Affiliation(s)
- Rebecca M Rentea
- Department of Surgery, Children's Mercy Hospital, 2401 Gillham Road, Kansas, MO, 64108, USA.
| | - Shawn D St Peter
- Department of Surgery, Children's Mercy Hospital, 2401 Gillham Road, Kansas, MO, 64108, USA
| | - Charles L Snyder
- Department of Surgery, Children's Mercy Hospital, 2401 Gillham Road, Kansas, MO, 64108, USA
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24
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Abstract
Appendicitis is one of the most common surgical pathologies in children. It can present with right lower quadrant pain. Scoring systems in combination with selective imaging and surgical examination will diagnose most children with appendicitis. Clinical pathways should be used. Most surgical interventions for appendicitis are now almost exclusively laparoscopic, with trials demonstrating better outcomes for children who undergo index hospitalization appendectomies when perforated. Nonoperative management has a role in the treatment of both uncomplicated and complicated appendicitis. This article discusses the workup and management, modes of treatment, and continued areas of controversy in pediatric appendicitis.
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Affiliation(s)
- Rebecca M Rentea
- Department of Surgery, Children's Mercy Hospital, 2401 Gillham Road, Kansas City, MO 64108, USA
| | - Shawn D St Peter
- Pediatric Surgical Fellowship and Scholars Programs, Department of Surgery, Children's Mercy Hospital, 2401 Gillham Road, Kansas City, MO 64108, USA.
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25
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Biomarkers of acute appendicitis: systematic review and cost-benefit trade-off analysis. Surg Endosc 2016; 31:1022-1031. [PMID: 27495334 PMCID: PMC5315733 DOI: 10.1007/s00464-016-5109-1] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2016] [Accepted: 07/09/2016] [Indexed: 12/12/2022]
Abstract
Background Acute appendicitis is the most common surgical emergency and can represent a challenging diagnosis, with a negative appendectomy rate as high as 20 %. This review aimed to evaluate the clinical utility of individual biomarkers in the diagnosis of appendicitis and appraise the quality of these studies. Methods A systematic review of the literature between January 2000 and September 2015 using of PubMed, OvidMedline, EMBASE and Google Scholar was conducted. Studies in which the diagnostic accuracy, statistical heterogeneity and predictive ability for severity of several biomarkers could be elicited were included. Information regarding costs and process times was retrieved from the regional laboratory. European surgeons blinded to these reviews were independently asked to rank which characteristics of biomarkers were most important in acute appendicitis to inform a cost–benefit trade-off. Sensitivity testing and the QUADAS-2 tool were used to assess the robustness of the analysis and study quality, respectively. Results Sixty-two studies met the inclusion criteria and were assessed. Traditional biomarkers (such as white cell count) were found to have a moderate diagnostic accuracy (0.75) but lower costs in the diagnosis of acute appendicitis. Conversely, novel markers (pro-calcitonin, IL 6 and urinary 5-HIAA) were found to have high process-related costs including analytical times, but improved diagnostic accuracy. QUADAS-2 analysis revealed significant potential biases in the literature. Conclusion When assessing biomarkers, an appreciation of the trade-offs between the costs and benefits of individual biomarkers is needed. Further studies should seek to investigate new biomarkers and address concerns over bias, in order to improve the diagnosis of acute appendicitis. Electronic supplementary material The online version of this article (doi:10.1007/s00464-016-5109-1) contains supplementary material, which is available to authorized users.
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26
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Abstract
Appendicitis represents the most common abdominal surgical emergency in the pediatric age group. Despite being a relatively common condition, the diagnosis of appendicitis in children can prove to be challenging in many cases. The goal of this article is to review the predictive utility for presenting signs and symptoms, laboratory tests, and imaging studies in the diagnostic work-up of appendicitis. Furthermore, we sought to explore the predictive utility of composite measures based on multiple sources of diagnostic information, as well as the utility of clinical pathways as a means to streamline the diagnostic process.
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Affiliation(s)
- Charity C Glass
- Department of Surgery, Children׳s Hospital Boston, Harvard Medical School, 300 Longwood Ave. Fegan-3, Boston, MA 02115
| | - Shawn J Rangel
- Department of Surgery, Children׳s Hospital Boston, Harvard Medical School, 300 Longwood Ave. Fegan-3, Boston, MA 02115.
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27
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Pham XBD, Sullins VF, Kim DY, Range B, Kaji AH, de Virgilio CM, Lee SL. Factors predictive of complicated appendicitis in children. J Surg Res 2016; 206:62-66. [PMID: 27916376 DOI: 10.1016/j.jss.2016.07.023] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2016] [Revised: 04/20/2016] [Accepted: 07/08/2016] [Indexed: 12/14/2022]
Abstract
BACKGROUND The ability to predict whether a child has complicated appendicitis at initial presentation may influence clinical management. However, whether complicated appendicitis is associated with prehospital or inhospital factors is not clear. We also investigate whether hyponatremia may be a novel prehospital factor associated with complicated appendicitis. MATERIALS AND METHODS A retrospective review of all pediatric patients (≤12 y) with appendicitis treated with appendectomy from 2000 to 2013 was performed. The main outcome measure was intraoperative confirmation of gangrenous or perforated appendicitis. A multivariable analysis was performed, and the main predictors of interest were age <5 y, symptom duration >24 h, leukocytosis (white blood cell count >12 × 103/mL), hyponatremia (sodium ≤135 mEq/L), and time from admission to appendectomy. RESULTS Of 392 patients, 179 (46%) had complicated appendicitis at the time of operation. Univariate analysis demonstrated that patients with complicated appendicitis were younger, had a longer duration of symptoms, higher white blood cell count, and lower sodium levels than patients with noncomplicated appendicitis. Multivariable analysis confirmed that symptom duration >24 h (odds ratio [OR] = 5.5, 95% confidence interval [CI] = 3.5-8.9, P < 0.01), hyponatremia (OR = 3.1, 95% CI = 2.0-4.9, P < 0.01), age <5 y (OR = 2.3, 95% CI = 1.3-4.0, P < 0.01), and leukocytosis (OR = 1.9, 95% CI = 1.0-3.5, P = 0.04) were independent predictors of complicated appendicitis. Increased time from admission to appendectomy was not a predictor of complicated appendicitis (OR = 0.8, 95% CI = 0.5-1.2, P = 0.2). CONCLUSIONS Prehospital factors can predict complicated appendicitis in children with suspected appendicitis. Hyponatremia is a novel marker associated with complicated appendicitis. Delaying appendectomy does not increase the risk of complicated appendicitis once intravenous antibiotics are administered. This information may help guide resource/personnel allocation, timing of appendectomy, and decision for nonoperative management of appendicitis in children.
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Affiliation(s)
- Xuan-Binh D Pham
- Department of General Surgery, Harbor-UCLA Medical Center, Torrance, California
| | - Veronica F Sullins
- Department of General Surgery, Harbor-UCLA Medical Center, Torrance, California
| | - Dennis Y Kim
- Department of General Surgery, Harbor-UCLA Medical Center, Torrance, California
| | - Blake Range
- Department of General Surgery, Harbor-UCLA Medical Center, Torrance, California
| | - Amy H Kaji
- Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, California; The Los Angeles Biomedical Research Institute at Harbor-UCLA, Torrance, California
| | - Christian M de Virgilio
- Department of General Surgery, Harbor-UCLA Medical Center, Torrance, California; The Los Angeles Biomedical Research Institute at Harbor-UCLA, Torrance, California
| | - Steven L Lee
- The Los Angeles Biomedical Research Institute at Harbor-UCLA, Torrance, California; Division of Pediatric Surgery, Department of Surgery, Harbor-UCLA Medical Center, Torrance, California.
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28
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Gorter RR, van den Boom AL, Heij HA, Kneepkens CMF, Hulsker CC, Tenhagen M, Dawson I, van der Lee JH. A scoring system to predict the severity of appendicitis in children. J Surg Res 2015; 200:452-9. [PMID: 26434504 DOI: 10.1016/j.jss.2015.08.042] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2015] [Revised: 07/24/2015] [Accepted: 08/21/2015] [Indexed: 12/26/2022]
Abstract
BACKGROUND It appears that two forms of appendicitis exist. Preoperative distinction between the two is essential to optimize treatment outcome. This study aimed to develop a scoring system to accurately determine the severity of appendicitis in children. MATERIALS AND METHODS Historical cohort study of pediatric patients (aged 0-17 y old) with appendicitis treated between January 2010 and December 2012. Division into simple, complex appendicitis, or another condition based on preset criteria. Multiple logistic regression analysis was used to build the prediction model with subsequent validation. RESULTS There were 64 patients with simple and 66 with complex appendicitis. Five variables explained 64% of the variation. Independent validation of the derived prediction model in a second cohort (55 simple and 10 complex appendicitis patients) demonstrated 90% sensitivity (54-99), 91% specificity (79-97), a positive predictive value of 64% (36-86), and an negative predictive value of 98% (88-100). The likelihood ratio+ was 10 (4.19-23.42), and likelihood ratio- was 0.11 (0.02-0.71). Diagnostic accuracy was 91% (84-98). CONCLUSIONS Our scoring system consisting of five variables can be used to exclude complex appendicitis in clinical practice if the score is <4.
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Affiliation(s)
- Ramon R Gorter
- Department of Paediatric Surgery, Paediatric Surgical Centre of Amsterdam, Emma Children's Hospital AMC & VU University Medical Centre, Amsterdam, The Netherlands; Department of Surgery, Red Cross Hospital, Beverwijk, The Netherlands.
| | | | - Hugo A Heij
- Department of Paediatric Surgery, Paediatric Surgical Centre of Amsterdam, Emma Children's Hospital AMC & VU University Medical Centre, Amsterdam, The Netherlands
| | - C M Frank Kneepkens
- Department of Paediatric Gastroenterology, VU University Medical Centre, Amsterdam, The Netherlands
| | - Caroline C Hulsker
- Department of Paediatric Surgery, Paediatric Surgical Centre of Amsterdam, Emma Children's Hospital AMC & VU University Medical Centre, Amsterdam, The Netherlands
| | - Mark Tenhagen
- Department of Surgery, Red Cross Hospital, Beverwijk, The Netherlands
| | - Imro Dawson
- Department of Surgery, IJsselland Hospital, Capelle aan Den IJssel, The Netherlands
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Anandalwar SP, Callahan MJ, Bachur RG, Feng C, Sidhwa F, Karki M, Taylor GA, Rangel SJ. Use of White Blood Cell Count and Polymorphonuclear Leukocyte Differential to Improve the Predictive Value of Ultrasound for Suspected Appendicitis in Children. J Am Coll Surg 2015; 220:1010-7. [PMID: 25708747 DOI: 10.1016/j.jamcollsurg.2015.01.039] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2014] [Revised: 01/12/2015] [Accepted: 01/12/2015] [Indexed: 11/30/2022]
Abstract
BACKGROUND The objective of this study was to examine the use of WBC count and polymorphonuclear leukocyte differential (PMN%) for improving the predictive value of ultrasound (US) in children with suspected appendicitis. STUDY DESIGN We conducted a retrospective cohort study of children undergoing US for suspected appendicitis between January 1, 2010 and December 31, 2012 at a single children's hospital (n=845). Negative (NPV) and positive predictive values (PPV) for appendicitis were calculated for common constellations of US findings and compared with and without the use of laboratory thresholds (WBC>9×10(3)/μL and PMN%>65% for PPV; WBC≤9×10(3)/μL and PMN%≤65% for NPV). RESULTS Fifty-one percent of US were considered "equivocal" (ie, appendix incompletely visualized, no primary or secondary signs, or presence of fluid only) and NPV increased significantly for this cohort using laboratory thresholds (41.9% vs 95.8%; p<0.001). Primary signs of appendicitis, without secondary signs, were documented in 18% of examinations, and the PPV associated with this cohort increased from 79.1% to 91.3% (p<0.001) using laboratory thresholds. Secondary signs with or without primary signs were documented in 24% of examinations, and laboratory thresholds improved the PPV in this cohort from 89.1% to 96.8% (p<0.001). Guidelines recommending against the use of CT for very high-risk and low-risk categories (NPV>95% and PPV>95%) on the basis of combined US and laboratory data could have reduced the number of CTs by 27.1% (101 of 373) during the study period. CONCLUSIONS The incorporation of WBC count and PMN% can substantially improve the predictive value of US in the diagnosis of suspected appendicitis in children.
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Affiliation(s)
| | | | - Richard G Bachur
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA
| | - Christina Feng
- Department of General Surgery, Boston Children's Hospital, Boston, MA
| | - Feroze Sidhwa
- Department of General Surgery, Boston Children's Hospital, Boston, MA
| | - Mahima Karki
- Department of General Surgery, Boston Children's Hospital, Boston, MA
| | - George A Taylor
- Department of Radiology, Boston Children's Hospital, Boston, MA
| | - Shawn J Rangel
- Department of General Surgery, Boston Children's Hospital, Boston, MA.
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Ngim CF, Quek KF, Dhanoa A, Khoo JJ, Vellusamy M, Ng CS. Pediatric appendicitis in a developing country: what are the clinical predictors and outcome of perforation? J Trop Pediatr 2014; 60:409-14. [PMID: 25063462 DOI: 10.1093/tropej/fmu037] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
OBJECTIVES This study explored the risk factors and outcomes associated with perforation in children who underwent emergency appendicectomies. METHODS A retrospective cross-sectional study was conducted on children <13 years old who underwent appendicectomies in a Malaysian hospital in 2007. RESULTS One hundred thirty-four children underwent appendicectomies of which 118 were confirmed histologically. Sixty-one (52%) were perforated. Children with perforation had significantly longer duration of symptoms (p < 0.001), higher white cell count and absolute neutrophil counts (p = 0.013), with longer intra-operative period (p < 0.001) and post-operative recovery period (p < 0.001). Of the 52 samples of pus collected intra-operatively, 37 (71.1%) yielded positive cultures that were predominantly Escherichia coli (n = 27). Both the patients who had Staphylococcus aureus cultured from pus collected intra-operatively had significant pyogenic complications (scrotal pyocele and intra-abdominal abscess). CONCLUSION Children whose appendicitis were perforated had longer duration of symptoms, higher white cell counts and absolute neutrophil counts. Those with S.aureus cultured from intra-operative pus appeared to suffer more complications.
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Affiliation(s)
- Chin Fang Ngim
- Department of Pediatrics, Johor Bahru Clinical School, Monash University Malaysia, 80100 Johor Bahru, Malaysia
| | - Kia Fatt Quek
- School of Medicine & Health Sciences, Monash University Malaysia, 46150 Selangor, Malaysia
| | - Amreeta Dhanoa
- Department of Microbiology, Monash University Malaysia, 46150 Selangor, Malaysia
| | - Joon Joon Khoo
- Department of Pathology, Johor Bahru Clinical School, Monash University Malaysia, 80100 Johor Bahru, Malaysia
| | - Muthualhagi Vellusamy
- Department of Surgery, Sultanah Aminah Hospital, Jalan Persiaran Abu Bakar Sultan, Johor Bahru, 80100 Johor, Malaysia
| | - Chen Siew Ng
- Department of Nuclear Medicine, Sultanah Aminah Hospital, Jalan Persiaran Abu Bakar Sultan, Johor Bahru, 80100 Johor, Malaysia
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Appendiceal inflammation affects the length of stay following appendicectomy amongst children: a myth or reality? Front Med 2013; 7:264-9. [PMID: 23620258 DOI: 10.1007/s11684-013-0259-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2012] [Accepted: 01/15/2013] [Indexed: 10/26/2022]
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