Perforation risk in pediatric appendicitis: assessment and management

Using shock index, pediatric age adjusted (SIPA) to predict prolonged length of stay in perforated appendicitis: a retrospective review

PURPOSE

Hospital length of stay (LOS) following admission for appendicitis is difficult to predict. Shock index, pediatric age adjusted (SIPA) accurately identifies severely injured trauma patients and predicts mortality among children admitted to the ICU. Our aim was to determine if elevated SIPA at presentation, and time to normalization of SIPA, can identify children with perforated appendicitis and predict hospital LOS.

METHODS

This was a retrospective cohort study of children 1-17 years admitted to a quaternary care referral center with appendicitis after appendectomy in 2021. The primary outcomes were presence of perforated appendicitis and hospital LOS. Generalized linear regressions were performed. Covariates included in all models were age, sex, fecalith, initial temperature, and time from diagnosis to OR.

RESULTS

We included 169 patients; 53 (31.4%) had perforated appendicitis. After adjustment, elevated SIPA was associated with presence of perforated appendicitis (p = 0.0002) and longer LOS (p < 0.0001). A patient presenting with appendicitis and elevated SIPA had 5.447 times higher odds of having perforated appendicitis (95% CI: 2.262, 13.826), a mean hospital LOS 2.047 times longer (95% CI: 1.564, 2.683), a mean time to toleration of regular diet 4.995 times longer (95% CI: 2.914, 8.918), and a mean duration of antibiotics that is 1.761 times longer (95% CI: 1.383, 2.243) than a patient with normal SIPA.

CONCLUSION

In children with appendicitis, elevated SIPA at presentation is associated with higher risk of perforation. These findings support the incorporation of SIPA during triage of patients with appendicitis and counseling families after surgery.

LEVEL OF EVIDENCE

Level 3.

Single-cell sequencing of the vermiform appendix during development identifies transcriptional relationships with appendicitis in preschool children

BACKGROUND

The development of the human vermiform appendix at the cellular level, as well as its function, is not well understood. Appendicitis in preschool children, although uncommon, is associated with a high perforation rate and increased morbidity.

METHODS

We performed single-cell RNA sequencing (scRNA-seq) on the human appendix during fetal and pediatric stages as well as preschool-age inflammatory appendices. Transcriptional features of each cell compartment were discussed in the developing appendix. Cellular interactions and differentiation trajectories were also investigated. We compared scRNA-seq profiles from preschool appendicitis to those of matched healthy controls to reveal disease-associated changes. Bulk transcriptomic data, immunohistochemistry, and real-time quantitative PCR were used to validate the findings.

RESULTS

Our analysis identified 76 cell types in total and described the cellular atlas of the developing appendix. We discovered the potential role of the BMP signaling pathway in appendiceal epithelium development and identified HOXC8 and PITX2 as the specific regulons of appendix goblet cells. Higher pericyte coverage, endothelial angiogenesis, and goblet mucus scores together with lower epithelial and endothelial tight junction scores were found in the preschool appendix, which possibly contribute to the clinical features of preschool appendicitis. Preschool appendicitis scRNA-seq profiles revealed that the interleukin-17 signaling pathway may participate in the inflammation process.

CONCLUSIONS

Our study provides new insights into the development of the appendix and deepens the understanding of appendicitis in preschool children.

Radiological diagnosis of severe appendicitis in 4 months infant with possible microperforation: A rare case report

Appendicitis is the most common cause of acute abdominal pain requiring surgical intervention; however, it is extremely rare in infants. Its diagnosis and treatment are challenging due to nonspecific clinical signs and symptoms. As a result, delayed or missed diagnosis is common in young children and is associated with an increased risk of perforation and peritonitis. We reported a case of a 4-month-old healthy male child. The patient presented with abdominal distention and fever. After ruling out other possible causes, he was diagnosed with acute appendicitis, which was confirmed by a CT scan. A gangrenous appendix, dilated bowel loops, and free fluid in the abdomen were discovered during surgery. An appendectomy was performed. The appendix in infants has an average length of 4.5 cm compared with 9.5 cm in adults. Infantile appendicitis is considered rare but cases have been documented also in neonates, misdiagnosis rates are high due to rarity in this age group in addition to nonspecific signs and symptoms, which led to a high perforation rate. Ultrasonography can diagnose appendicitis in children with a sensitivity and specificity of 90%-95% without subjecting the child to radiation. A physician should always keep the diagnosis of appendicitis in mind in the infant age group, even though it is rare, as a delay in diagnosis and treatment has been associated with an increased risk of complications including appendicular perforation and peritonitis.

Ultrasound imaging of bowel obstruction in infants and children

We review the etiologies of bowel obstruction in infants and children that can be identified on ultrasound (US) including perforated appendicitis, intussusception, foreign body ingestion, colonic volvulus, intra-abdominal mass lesions, internal hernia, and stricturing inflammatory bowel disease. US can potentially identify the cause of bowel obstruction in these age groups, without the need for additional cross-sectional imaging, and can aid in patient management including interventional and surgical planning. Hence, it is important to be familiar with the sonographic imaging findings of bowel obstruction in infants and children.

Improving Accuracy of Administrative Data for Perforated Appendicitis Classification

INTRODUCTION

Reliance on International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) diagnosis codes may misclassify perforated appendicitis with resultant research, fiscal, and public health implications. We aimed to improve the accuracy of administrative data for perforated appendicitis classification relying on ICD-10-CM codes from 2015 to 2018.

METHODS

We conducted a retrospective study of randomly sampled patients aged ≤18 years diagnosed with acute appendicitis from eight children's hospitals. Patients were identified using the Pediatric Health Information System, and true perforation status was determined by medical record review. We developed two algorithms by leveraging Pediatric Health Information System data elements and data mining (DM) approaches. The two developed algorithm performance was compared against algorithms that exclusively relied on ICD-10-CM codes using area under the curve and other measures.

RESULTS

Of 1051 clinically validated encounters that were included, 383 (36.4%) patients were identified to have perforated appendicitis. The two algorithms developed using DM approaches primarily leveraged ICD-10-CM codes and length of stay. DM-developed algorithms had a significantly higher accuracy than algorithms relying exclusively on ICD-10-CM (P value < 0.01): sensitivity and specificity for DM-developed algorithms were 0.86-0.88 and 0.95-0.97, respectively, which were overall higher than algorithms that relied on only ICD-10-CM.

CONCLUSIONS

This study provides an algorithm that can improve the accuracy of perforated appendicitis classification using commonly available elements in administrative data. We recommend that this algorithm is used in future appendicitis classification to ensure valid reporting, hospital-level benchmarking, and fiscal or public health assessments.

Risk Factors Associated With Negative Appendicectomy Rates: A Retrospective Cohort Study

BACKGROUND

Acute appendicitis (AA) is the most common emergency general surgical condition worldwide. Diagnosis is challenging and incorporates clinical, biochemical and radiological investigations. Our aim was to provide data from routine practice investigating widely utilised diagnostic methods from a single centre within the United Kingdom.

METHODS

We conducted a retrospective observational cohort study of patients who underwent a laparoscopic appendicectomy for AA between April 2022 and March 2023. AA was defined as the presence of transmural polymorphonuclear leukocytes in histology. Subgroup analysis was performed on paediatric patients. Factors associated with AA were investigated, and the diagnostic utility of biochemical and radiological investigations was examined.

RESULTS

A total of 330 appendicectomies were analysed. We found an overall negative appendicectomy rate (NAR) of 38% and 48% in paediatric patients. Independent factors associated with AA on the multivariate analysis included elevated neutrophil counts (>7 × 109/L) (OR 4.04), elevated CRP (>5 mg/L) (OR 3.04) and a radiological diagnosis (OR 8.0). Computerised tomography (CT) and ultrasound had sensitivity/specificity of 98%/47% and 35%/86%, respectively. The positive-predictive values were 85% for CT and 50% for ultrasound, and the negative-predictive values were 86% for CT and 77% for ultrasound.

CONCLUSION

Our study has highlighted the importance of utilising a combination of factors to improve the diagnostic certainty of AA. However, our routine practice data have shown different sensitivities and specificities of imaging in comparison to existing literature, resulting in a high NAR. Further real-world data are needed to understand whether these differences from the existing data are seen in other clinical settings.

Applying an explainable machine learning model might reduce the number of negative appendectomies in pediatric patients with a high probability of acute appendicitis

The diagnosis of acute appendicitis and concurrent surgery referral is primarily based on clinical presentation, laboratory and radiological imaging. However, utilizing such an approach results in as much as 10-15% of negative appendectomies. Hence, in the present study, we aimed to develop a machine learning (ML) model designed to reduce the number of negative appendectomies in pediatric patients with a high clinical probability of acute appendicitis. The model was developed and validated on a registry of 551 pediatric patients with suspected acute appendicitis that underwent surgical treatment. Clinical, anthropometric, and laboratory features were included for model training and analysis. Three machine learning algorithms were tested (random forest, eXtreme Gradient Boosting, logistic regression) and model explainability was obtained. Random forest model provided the best predictions achieving mean specificity and sensitivity of 0.17 ± 0.01 and 0.997 ± 0.001 for detection of acute appendicitis, respectively. Furthermore, the model outperformed the appendicitis inflammatory response (AIR) score across most sensitivity-specificity combinations. Finally, the random forest model again provided the best predictions for discrimination between complicated appendicitis, and either uncomplicated acute appendicitis or no appendicitis at all, with a joint mean sensitivity of 0.994 ± 0.002 and specificity of 0.129 ± 0.009. In conclusion, the developed ML model might save as much as 17% of patients with a high clinical probability of acute appendicitis from unnecessary surgery, while missing the needed surgery in only 0.3% of cases. Additionally, it showed better diagnostic accuracy than the AIR score, as well as good accuracy in predicting complicated acute appendicitis over uncomplicated and negative cases bundled together. This may be useful in centers that advocate for the conservative treatment of uncomplicated appendicitis. Nevertheless, external validation is needed to support these findings.

Spondylodiscitis Following Perforated Acute Appendicitis: A Case Report

Spondylodiscitis is a multifactorial disease of significant medical and socioeconomic importance, the treatment of which presents a challenge to clinicians and surgeons. Acute appendicitis is a common inflammatory disease in children, with postoperative complications occurring in up to 55% of cases. We present the case of a 15-year-old male with symptoms of severe back pain and fever two months following surgery for perforated appendicitis. The computed tomography (CT) revealed spondylodiscitis of T12-L1 spinal level. Discectomy and posterior pedicle-screw fixation were performed, followed by antibiotic treatment resulted in the resolution of preoperative symptoms. To the best of our knowledge, this is the third case of spondylodiscitis after perforated acute appendicitis in literature. Timely diagnosis and treatment in cases of spondylodiscitis are prerequisites for lowering the rate of permanent neurological deficits in these patients.

Perforated Appendicitis in Children: Management, Microbiology, and Antibiotic Stewardship

Although appendicitis has been described for more than 300 years, its optimal management remains a topic of active investigation. Acute appendicitis is the most common cause of peritonitis in children, and rates of perforated appendicitis are much higher in children than in adults. Increased risk for perforated appendicitis in children is related to a delay in diagnosis due to age, size, access to care, and more. Surgical options include immediate appendectomy versus nonoperative management with intravenous antibiotics ± a drainage procedure, with a subsequent interval appendectomy. Microbiota of perforated appendicitis in children most often includes Escherichia coli, Bacteroides fragilis, Streptococcus, and more. Even though the most common organisms are known, there is a large variety of practice when it comes to postoperative antibiotic management in these patients. Studies discuss the benefits of mono- versus dual or triple therapy without a particular consensus regarding what to use. This is reflected across differing practices at various institutions. In this review, we aim to explore the implications of perforated appendicitis in pediatrics, common organisms seen, antibiotic regimen coverage, and the implications of variations of practice. Resistance to commonly used broad-spectrum antibiotics is evolving, therefore minimization of care variability is needed for improved patient outcomes and proper antibiotic stewardship.

Spondylodiscitis following perforated acute appendicitis in a 14-year-old female: A case report

INTRODUCTION AND IMPORTANCE

Acute appendicitis is a common surgical emergency, often resulting in perforation and increased morbidity. Up to 55 % of children with complicated appendicitis may experience a complication such as infection, bowel obstruction, or unplanned hospital re-admission (Blakely et al., 2011 [23]). However, the development of infectious spondylodiscitis following appendectomy is an extremely rare complication, particularly in pediatric patients. We present the first reported case of lumbar spondylodiscitis occurring post-perforated appendicitis in a 14-year-old female, highlighting the importance of recognizing and managing uncommon complications.

CASE PRESENTATION

A previously healthy 14-year-old female underwent urgent appendectomy for perforated appendicitis. Postoperatively, she developed severe back pain and immobility. Imaging revealed early lumbar discitis, and Pseudomonas aeruginosa was isolated from the surgical site. The patient received multiple antibiotic regimens, including vancomycin, ceftazidime, and meropenem, resulting in clinical improvement.

CLINICAL DISCUSSION

Infectious spondylodiscitis is typically hematogenously spread or due to direct inoculation. In this case, the spread from a contiguous focus of infection without vascular insufficiency is suspected. The coexistence of appendicitis and spondylodiscitis poses diagnostic challenges, requiring a multidisciplinary approach for accurate diagnosis and appropriate treatment.

CONCLUSION

This unique case highlights the need for vigilance in recognizing rare complications of appendicitis, such as infectious spondylodiscitis. Early diagnosis and tailored antibiotic therapy are crucial for optimal outcomes. Further research is needed to explore the underlying mechanisms and risk factors associated with this rare complication.

Tryptase in Acute Appendicitis: Unveiling Allergic Connections through Compelling Evidence

The aetiology of acute appendicitis (AA), the most frequent abdominal surgical emergency, is still unclarified. Recent epidemiologic, clinical and laboratorial data point to an allergic component in the pathophysiology of AA. Mastocytes participate in the Th2 immune response, releasing inflammatory mediators from their granules upon stimulation by IgE-specific antigens. Among the well-known mediators are histamine, serotonin and tryptase, which are responsible for the clinical manifestations of allergies. We conducted a prospective single-centre study to measure histamine and serotonin (commercial ELISA kit) and tryptase (ImmunoCAP System) concentrations in appendicular lavage fluid (ALF) and serum. Consecutive patients presenting to the emergency department with a clinical diagnosis of AA were enrolled: 22 patients with phlegmonous AA and 24 with gangrenous AA The control group was composed of 14 patients referred for colectomy for colon malignancy. Appendectomy was performed during colectomy. Tryptase levels were strikingly different between histological groups, both in ALF and serum (p < 0.001); ALF levels were higher than serum levels. Tryptase concentrations in ALF were 109 times higher in phlegmonous AA (APA) (796.8 (194.1-980.5) pg/mL) and 114 times higher in gangrenous AA (AGA) (837.4 (272.6-1075.1) pg/mL) than in the control group (7.3 (4.5-10.3) pg/mL. For the diagnosis of AA, the discriminative power of serum tryptase concentration was good (AUC = 0.825), but discriminative power was weak (AUC = 0.559) for the differential diagnosis between APA and AGA. Mastocytes are involved in AA during clinical presentations of both phlegmonous and gangrenous appendicitis, and no significant differences in concentration were found. No differences were found in serum and ALF concentrations of histamine and serotonin between histological groups. Due to their short half-lives, these might have elapsed by the time the samples were collected. In future research, these determinations should be made immediately after appendectomy. Our findings confirm the hypersensitivity type I reaction as an event occurring in the pathogenesis of AA: tryptase levels in ALF and serum were higher among patients with AA when compared to the control group, which is in line with a Th2 immune response and supports the concept of the presence of an allergic reaction in the pathogenesis of acute appendicitis. Our results, if confirmed, may have clinical implications for the treatment of AA.

A Case Series of Appendicitis and Pseudo-appendicitis in a Paediatric Intensive Care Unit

INTRODUCTION

Appendicitis is a common childhood condition that can be diagnostically challenging. Severe cases may necessitate support in the critical or intensive care unit. These "critical appendicitis diagnoses" have rarely been described.

CASE DESCRIPTION

We retrospectively reviewed the Paediatric Intensive Care Unit (PICU) database of the Hong Kong Children's Hospital and identified cases of suspected and confirmed appendicitis. Clinical features, radiologic findings and final diagnosis of each case were summarized and reported in this case series. We review six anonymized cases of appendicitis managed in a PICU to illustrate the different age spectrum and clinical manifestations of the condition. Rupture of the inflamed appendix, peritonitis and pancreatitis were some of the complications encountered. Crohn's disease was found in one case as an underlying diagnosis. Also, one girl clinically diagnosed with appendicitis was found to be a case of ruptured hepatoblastoma with no appendicitis (i.e., pseudoappendicitis).

CONCLUSION

Prompt diagnosis, surgical removal of the inflamed appendix, and use of appropriate antimicrobials when indicated are essential in reducing mortality and morbidity associated with severe appendicitis. Significant premorbid conditions such as acute myeloid leukemia, Mitochondrial Encephalopathy Lactic Acidosis Syndrome (MELAS), inflammatory bowel disease and complications may be present in patients needing intensive care as is illustrated in the present cases. Pseudoappendicitis is an important differential diagnosis. Imaging is crucial and useful in establishing and confirming the diagnosis of appendicitis and pseudo-appendicitis in these PICU cases.

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.

Effects of menthol gum chewing on postoperative nausea, vomiting, and length of hospital stay in children undergoing appendectomy: A randomized controlled trıal

PURPOSE

This study aimed to determine the effects of menthol gum chewing on nausea, vomiting, and length of hospital stay after appendectomy in children.

BACKGROUND

Postoperative nausea and vomiting (PONV) can be induced by general anesthesia. Several drugs are available to reduce the risk of PONV; however, their cost and side effects limit their clinical use.

METHOD

This was a randomized controlled clinical trial that included 60 children aged 7-18 years who underwent an appendectomy at the Pediatric Surgery Clinic of a tertiary hospital between April and June 2022. Data for this study were collected via the developed information form, which included participants' descriptive characteristics and bowel function parameters, and the Baxter Retching Faces (BARF) nausea scale. Children in the study group who underwent an appendectomy were given chewing gum and asked to chew it for an average of 15 min, whereas those in the control group received no intervention.

RESULTS

The BARF nausea score measured during the menthol gum chewing period was lower in the study group, and the difference score value calculated after pretest time was higher in the study group, as expected (p < 0.001). Moreover, menthol gum chewing was found to shorten hospital stay by 1 day (p < 0.05).

CONCLUSION

Menthol gum chewing reduced the severity of postoperative nausea and length of hospital stay.

PRACTICE IMPLICATION

Chewing gum can be used as a nonpharmacological method by pediatric nurses in clinical practice to reduce the severity of postoperative nausea and length of hospital stay.

Appendicitis and its associated mortality and morbidity in infants up to 3 months of age: A systematic review

Background and Aims

Although appendicitis is rare in young infants, the reported mortality is high. Primary aim of this systematic review was to provide updated insights in the mortality and morbidity (postoperative complications, Clavien-Dindo grades I-IV) of appendicitis in infants ≤3 months of age. Secondary aims comprised the evaluation of patient characteristics, diagnostic work-up, treatment strategies, comorbidity, and factors associated with poor outcome.

Methods

This systematic review was reported according to the PRISMA statement with a search performed in Pubmed, Embase and Web of Science (up to September 5th 2022). Original articles (published in English ≥1980) reporting on infants ≤3 months of age with appendicitis were included. Both patients with abdominal appendicitis and herniated appendicitis (such as Amyand's hernia) were considered. Data were provided descriptively.

Results

In total, 131 articles were included encompassing 242 cases after identification of 4294 records. Overall, 184 (76%) of the 242 patients had abdominal and 58 (24%) had herniated appendicitis. Two-hundred (83%) of the patients were newborns (≤28 days) and 42 (17%) were infants between 29 days and ≤3 months of age. Either immediate, or after initial conservative treatment, 236 (98%) patients underwent surgical treatment. Some 168 (69%) patients had perforated appendicitis. Mortality was reported in 20 (8%) patients and morbidity in an additional 18 (8%). All fatal cases had abdominal appendicitis and fatal outcome was relatively more often reported in newborns, term patients, patients with relevant comorbidity, nonperforated appendicitis and those presented from home.

Conclusion

Mortality was reported in 20 (8%) infants ≤3 months of age and additional morbidity in 18 (8%). All patients with fatal outcome had abdominal appendicitis. Several patient characteristics were relatively more often reported in infants with poor outcome and adequate monitoring, early recognition and prompt treatment may favour the outcome.

Evaluation of the outcome of right subumbilical transverse incision approach for the management of complicated appendicitis in paediatric age group - A multi-institutional retrospective study

Aim

The aim is to evaluate the outcome of right subumbilical transverse incision approach for the management of complicated appendicitis in paediatric age group.

Materials and Methods

This is a retrospective multi-institutional study which was conducted in the Department of Paediatric Surgery, I Q City Medical College and Hospital, Durgapur, West Bengal, India and the Department of Paediatric Surgery, Rajiv Gandhi Super Speciality Hospital/Raichur Institute of Medical Sciences, Raichur, Karnataka, India. In this study, a review of 77 paediatric patients operated for complicated appendicitis using a right subumbilical transverse incision approach was done for a period of 3 years (from December 2017 to December 2020). All patients had proven complicated appendicular pathology like appendicular perforation, appendicular abscess or complicated appendicular lumps on ultrasonography or computed tomography scan, which mandated exploration.

Results

There was no mortality. Average operative time was 1 h 48 min (ranging from 58 min to 3 h 12 min). Average length of hospital stay was 9 days (ranging from 5 days to 13 days). There was no incidence of fecal fistula. Seventeen (22%) patients developed superficial surgical site infection which subsided with regular dressings. There was no incidence of wound dehiscence or burst abdomen. Five (6.5%) patients required the incision to be extended beyond the midline to the left side to deal with the pathology and to access the entire peritoneal cavity. Nine (11.6%) patients required loop ileostomies, which was fashioned on the lateral aspect of the transverse incision. Only one patient had a doubtful caecal injury which was repaired and loop ileostomy was done. Six patients (7.7%) had adhesive intestinal obstruction postoperatively, of which three required re-exploration. There was no incidence of incisional hernia or any stoma-related complications.

Conclusion

Complicated appendicitis is a condition which lacks standardisation of approach for management, and is inherently associated with complications. However, with a more logical incision and intra-operative approach we can keep the complications to minimum and improve outcomes to great extent in those patients requiring surgical intervention. We have been using the subumbilical transverse incision in all sizes of patients ranging from small children to adolescents with excellent results, and we believe that the same approach can be applied even in adult patients in similar clinical scenarios.

Eosinophil Granule Proteins Involvement in Acute Appendicitis-An Allergic Disease?

Several pieces of evidence point to an allergic component as a trigger of acute appendicitis. As the Th2 immune response is characterized by eosinophil mobilization to the target organ and release of their cationic granule proteins, it is reasonable to investigate if the degranulation of eosinophils could be associated with the local injury. The primary aim of this study is to evaluate the participation of eosinophils granules proteins in acute appendicitis, both at local and systemic levels and the secondary aim is to evaluate the diagnostic accuracy of eosinophils granules proteins for the detection of acute appendicitis, as well as for distinguishing between complicated and uncomplicated acute appendicitis. Eosinophil-derived neurotoxin (EDN), eosinophil cationic protein (ECP) and eosinophil peroxidase (EP) are the most well-known eosinophil granule proteins. From August 2021 to April 2022, we present a prospective single-center study to evaluate the EDN, ECP, and EP concentrations simultaneously in appendicular lavage fluid (ALF) and the serum of 22 patients with acute phlegmonous appendicitis (APA), 24 with acute gangrenous appendicitis (AGA), and 14 normal controls. Concerning EDN, no differences were found between groups. ECP concentrations in ALF and serum were significantly higher in the histologically confirmed acute appendicitis compared to the control groups (p < 0.0001 and p < 0.0001, respectively). In ALF, no differences were found between ECP levels in APA: 38.85 ng/mL (IQR 26.50-51.77) and AGA 51.55 ng/mL (IQR 39.55-70.09) groups (p = 0.176). In the serum, no difference was found between ECP levels at APA: 39 ng/mL (IQR 21.30-56.90) and AGA: 51.30 ng/mL (IQR 20.25-62.59) (p = 0.100). For EP, the concentrations in ALF (p < 0.001) and serum (p < 0.001) were both higher in acute appendicitis compared to the control. In ALF, no difference was found between APA: 240.28 ng/mL (IQR 191.2-341.3) and AGA: 302.5 (IQR 227.7-535.85) (p = 0.236). In the serum, no differences were found between APA: 158.4 ng/mL (IQR 111.09-222.1) and AGA: 235.27 (IQR 192.33-262.51) (p = 0.179). Globally, the ALF concentrations were higher than serum concentrations, reflecting an intense inflammatory local reaction in AA. The optimal ECP cut-off for discriminating between acute appendicitis and the controls was >11.41 ng/mL, with a sensitivity of 93.5%, but with a specificity for identifying appendicitis of 21.4%, good discriminative power (AUC = 0.880). For EP, the optimal cut-off was >93.20 ng/mL, with a sensitivity of 87%, but with a specificity of 14.3% (AUC = 0.901), excellent discriminative power. For the diagnosis of perforated AA, the discriminative power of ECP and EP serum concentrations are weak (AUC = 0.562 and AUC = 0.664, respectively). Concerning the presence of peritonitis, the discriminative power of ECP and EP serum concentrations is acceptable, respectively: AUC = 0.724 and AUC = 0.735. Serum levels of EDN (p = 0.119), ECP (p = 0.586) and EP (p = 0.08) in complicated appendicitis were similar to uncomplicated appendicitis. Serum concentrations of ECP and EP can be added to decision-making AA diagnosis. A Th2-type immune response is present in AA. These data bring forward the role of an allergic reaction in the pathogenesis of acute appendicitis.

Post-discharge antibiotics do not prevent intra-abdominal abscesses after appendectomy in children

AIM OF THE STUDY

Perforated appendicitis is common in children, often associated with long hospital stays and high risk of complications. There has been much discussion regarding whether antibiotics prescribed after discharge might reduce the risk of intra-abdominal abscess. This study aims to evaluate whether giving post-discharge antibiotics after appendectomy for perforated appendicitis reduces the risk of abscess.

METHOD

After obtaining IRB approval, we reviewed the records of 363 patients who underwent appendectomy for perforated appendicitis at our tertiary pediatric institution from July 2015 to December 2021. Based on surgeon's preference, patients comprised two groups: those discharged with antibiotics (n = 86) or without antibiotics (n = 277). We compared post-discharge ED visits, 30-day readmissions, and SSI, analyzed with population proportion Z-tests with significance levels of 0.05.

RESULTS

Post-discharge organ-space infections occurred in 4/86 (4.7%) of those with antibiotics and 9/277 (3.2%) of those without (P = 0.54). Post-discharge ED visits occurred in 10/86 (11.6%) for those with antibiotics and 23/277 (8.3%) for those without (P = 0.35). Thirty-day readmissions occurred in 6/86 (7.0%) for those with antibiotics and 10/277 (3.6%) for those without (P = 0.18). Superficial and deep SSI occurred in 0/86 (0%) for those with antibiotics and 5/277 (1.8%) for those without (P = 0.21).

CONCLUSION

In children who underwent appendectomy for perforated appendicitis, antibiotics prescribed after discharge did not reduce the incidence of intra-abdominal abscess, ED visits, or SSI. Given appropriate clinical judgment, it is safe to discharge patients with perforated appendicitis home without antibiotics.

LEVEL OF EVIDENCE

Level III treatment study: retrospective comparative study.

Development and evaluation of a patient decision aid for pediatric interval appendectomy

Objective

One option for the treatment of perforated appendicitis in pediatric patients is interval appendectomy (IA). A patient decision aid (PDA) can be useful in the decision-making process regarding IA. The purpose of this study was to evaluate parents' decisional conflict before and after engaging with a developed PDA.

Methods

Participants included (a) parents who are considering IA surgery for their child, (b) have not yet had their follow-up appointment postdischarge, and (c) were fluent in either the official languages of English or French. This study used a pretest and post-test design to measure participants' decisional conflict and treatment option choice. Perceptions and acceptability of the PDA were also assessed.

Results

A total of 18 participants completed the study (16 mothers). Major findings include significant decreases in all Decisional Conflict Scale items from pre-PDA to post-PDA engagement, except for one item. The majority of participants perceived the PDA to be useful, easy to find information regarding risks and provided enough information to help them make a decision regarding their child's treatment.

Conclusions

This is the first study to develop and evaluate a PDA among parents who are making a decision regarding IA surgery. The results showed a significant decrease in decisional conflict after using the PDA. The results also showed that the PDA was generally accepted among parents and had positive perceptions regarding length, content, and balance. The use of PDA for this population can help ease feelings of decisional conflict and equip parents with the information to make informed decisions.

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.

Pediatrik Apandisit Olgularında Ultrasonografinin Tanısal Duyarlılığı

Amaç: Çalışmamızda pediatrik yaş grubunda ultrasonografinin apandisit tanısındaki duyarlılığının araştırılması amaçlanmıştır. Gereç Yöntem: Operasyon sonucu apandisit tanısı alan, preoperatif USG tetkiki gerçekleştirilmiş olan ve akut batın nedeni olan ek patolojisi bulunmayan 87 pediatrik olgu çalışmaya dahil edildi. Olguların USG raporları retrospektif olarak incelenerek USG’ nin apandisit tanısındaki duyarlılığı araştırıldı. Ayrıca olguların lökosit sayıları, nötrofil oranları ve CRP değerleri hastane arşivinden ve varsa BT tetkikleri PACS sisteminden incelendi. Bulgular: Olguların %71’i akut apandisit, %29’u perfore apandisitti. Olguların %74’ünün USG’si apandisit ile uyumlu olup USG’nin tanı duyarlılığı %74’dü, %16 olguda USG’de sekonder apandisit bulguları izlenirken %10 olguda USG tetkiki tamamen normaldi. USG ile tanı konulamayan %26 olgudan %10 olgunun tanısı BT ile konulmuş olup %16 olguda tanıya klinik bulgularla gidilmişti. Olguların %62’sinde lökositoz, %84’ünde nötrofil oranında artış (sola kayma), %86’sında ise CRP yüksekliği bulunmaktaydı ve olguların tamamında bu parametrelerin en az biri yüksekti. Sonuç: Ultrasonografi her durumda tanı koymak için yeterli olmasa da çalışmamızda ulaşılan yüksek duyarlılık oranı, ultrasonografinin akut apandisit şüphesi bulunan pediatrik hastalarda ilk seçenek tanı aracı olarak kullanılabileceği bilgisini desteklemektedir.

Comparison of the RIPASA and Labeda Scoring Systems to Assess the Morphological Severity of Acute Appendicitis

BACKGROUND: Acute appendicitis is the most common emergency surgical case, leading to further complications if not treated immediately. Limited diagnostics infrastructure is an obstacle in developing countries, especially in the regions. Therefore, alternatives such as clinical scoring systems are required to assist in diagnosis. AIM: This study aimed to compare the use of the RIPASA and Labeda scores to assess the severity of acute appendicitis morphology by determining the accuracy, sensitivity, specificity, positive predictive value, negative predictive value, and negative appendectomy rate. METHODS: This was a cross-sectional study designed to assess the severity of morphology of intra-operative acute appendicitis in Dr. Chasan Boesoirie Hospital and network hospitals in Ternate, North Maluku, Indonesia. Data regarding patient characteristics, leukocytes, and acute appendicitis severity were collected and analyzed alongside RIPASA and Labeda scores using the Chi-square test. p < 0.05 were considered statistically significant. RESULTS: Of 59 cases, 39 (66.1%) were complicated acute appendicitis and 20 (33.9%) were noncomplicated acute appendicitis. Chi-square test results showed that there was a significant relationship (p ≤ 0.001) between RIPASA/Labeda scores and the severity of acute appendicitis morphology. CONCLUSION: RIPASA and Labeda scores had the same accuracy, sensitivity, specificity, positive predictive value, and negative predictive value for acute appendicitis severity. Thus, RIPASA and Labeda scores can be used by physicians to help establish a diagnosis of acute appendicitis and determine the need for emergency surgery, as well as predict the possibility of morbidity/complications in patients.

Pelvic Health Assessment in Adult Females Following Pediatric Appendicitis: A Monocentric Retrospective Case-Control Study

Background: The anatomical location of the appendix in females determines its close contact with the internal genitalia, involving the latter in case of acute appendicitis (AA). The aim of this study was to evaluate the incidence of pelvic health impairment in adult women who underwent appendicectomy during childhood. Materials and Methods: A retrospective observational study was conducted including all female patients who underwent appendicectomy for acute appendicitis at our Center between January 1985 and December 1995. The patients were divided into two groups, i.e., complicated AA (Group A) and not complicated AA (Group B), and were asked to respond to a questionnaire investigating their general health status, fertility impairment, ectopic pregnancies, miscarriages, endometriosis, and chronic pelvic pain. The same questionnaire was administered to female volunteers with past medical history (PMH) negative for AA. The data were compared using chi-square test and Fisher exact test (a p value < 0.05 was considered for statistical significance). Results: In total, 75 patients operated for AA during childhood (22 in Group A and 53 in group B) and 44 female volunteers with PMH negative for AA (group C) were enrolled in the study. Seventeen patients (77.3%) in group A, 40 (75.4%) in group B, and 29 (65.9%) in group C (p > 0.05) had pregnancies. The number of miscarriages among women who became pregnant in their life was 5 in group A, 13 in group B, and 12 in group C (p > 0.05). Chronic pelvic pain was reported by 7 out of 22 (31.8%) patients in group A, 7 out of 53 (13.2%) in group B, and 5 out of 44 (11.4%) in group C (A vs. C: p = 0.04, OR = 3.64; A vs. B: p = 0.06 and B vs. C: p = 0.52). Conclusions: In our series, AA, complicated or not, neither determined repercussions on fertility, risk of miscarriages, and ectopic pregnancies nor increased the risk of developing endometriosis. However, women who experienced complicated AA showed a higher prevalence of chronic pelvic pain onset in adulthood compared to healthy women.

Association Between Neighborhood-Level Social Determinants of Health and Access to Pediatric Appendicitis Care

IMPORTANCE

Presenting with complicated appendicitis, which is associated with higher rates of complications and readmissions compared with simple appendicitis, may indicate delayed access to care. Although both patient-level and neighborhood-level social determinants of health are associated with access to care, little is known about the association between neighborhood factors and access to acute pediatric surgical care.

OBJECTIVE

To examine the association between neighborhood factors and the odds of presenting with complicated appendicitis and unplanned postdischarge health care use.

DESIGN, SETTING, AND PARTICIPANTS

A retrospective cohort study of patients aged 18 years or younger diagnosed with appendicitis was conducted. Discharge data from October 1, 2015, to September 30, 2018, were obtained from the Pediatric Health Information System Database and linked to the Child Opportunity Index (COI) 2.0 Database. Data analysis was conducted from January 1 through July 1, 2021.

EXPOSURES

The COI, a composite score of zip code neighborhood opportunity level information, divided into quintiles ranging from very low to very high opportunity.

MAIN OUTCOMES AND MEASURES

Based on COI level, the main outcome was the odds of presenting with complicated appendicitis, which was defined using the Agency for Healthcare Research and Quality-specified International Statistical Classification of Diseases, 10th Edition, Clinical Modification codes. The secondary outcome was the odds of unplanned postdischarge health care use (emergency department visits and/or readmissions) for patients with simple and with complicated appendicitis.

RESULTS

A total of 67 489 patients (mean [SD] age, 10.5 [3.9] years) had appendicitis, with 31 223 cases (46.3%) being complicated. A total of 1699 patients (2.5%) were Asian, 24 234 (35.9%) were Hispanic, 4447 (6.6%) were non-Hispanic Black, and 29 234 (43.3%) were non-Hispanic White; 40 549 patients (60.1%) were male; and 32 343 (47.9%) were publicly insured. Patients living in very low-COI neighborhoods had 28% higher odds of presenting with complicated appendicitis (odds ratio, 1.28; 95% CI, 1.20-1.35) compared with those in very high-COI neighborhoods. There was no significant association between COI level and unplanned postdischarge health care use (very high COI, 20.8%; very low COI, 19.1%).

CONCLUSIONS AND RELEVANCE

In this cohort study, children from lower-COI neighborhoods had increased odds of presenting with complicated appendicitis compared with those from higher-COI neighborhoods, even after controlling for patient-level social determinants of health factors. These findings may inform policies and programs that seek to improve access to pediatric surgical care.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Larger Physique as a Risk Factor for Infantile Appendicitis: A Retrospective Study

The clinical features and risk factors of acute appendicitis in infants are unclear. Our aim was to evaluate the association between anthropometrics and the occurrence of infantile appendicitis. This was a retrospective study of infants (<6 years of age) and school-age children (6-10 years of age) of Asian ethnicity who required hospitalization for appendicitis at our two participating institutions between 2004 and 2018. The Z-score for height, body weight, and body mass index (BMI) was compared between the two groups, as well as between patients presenting with perforated and non-perforated appendicitis. The analysis included data from 73 infants and 362 school-age children. Z-scores were greater in infants than in school-age children for height (0.37 versus -0.03, p = 0.003) and body weight (0.12 versus -0.36, p = 0.023), with no between-group difference for the Z-score of BMI. There was no difference in Z-scores for height, weight, and BMI between the perforated and non-perforated appendicitis infant groups. Infants presenting with acute appendicitis were characterized by a larger physique but with normal proportion. This trend was not observed in school-age children. Therefore, larger infants presenting with abdominal pain should be screened for appendicitis.

Pre-Coronavirus Disease 2019 Pediatric Acute Appendicitis: Risk Factors Model and Diagnosis Modality in a Developing Low-Income Country

PURPOSE

Pediatric acute appendicitis has a stable incidence rate in Western countries with an annual change of -0.36%. However, a sharp increase was observed in the Asian region. The Indonesian Health Department reveals appendicitis as the fourth most infectious disease, with more than 64,000 patients annually. Hence, there is an urgent need to identify and evaluate the risk factors and diagnostic modalities for accurate diagnosis and early treatment. This study also clarifies the usage of pediatric appendicitis score (PAS) for children <5 years of age.

METHODS

The current study employed a cross-sectional design with purposive sampling through demographic and PAS questionnaires with ultrasound sonography (USG) results. The analysis was performed using the chi-square and Mann-Whitney tests and logistic regression.

RESULTS

This study included 21 qualified patients with an average age of 6.76±4.679 years, weighing 21.72±10.437 kg, and who had been hospitalized for 4.24±1.513 days in Siloam Teaching Hospital. Compared to the surgical gold standard, PAS and USG have moderate sensitivity and specificity. Bodyweight and stay duration were significant for appendicitis (p<0.05); however, all were confounders in the multivariate regression analysis. Incidentally, a risk prediction model was generated with an area under the curve of 72.73%, sensitivity of 100.0%, specificity of 54.5%, and a cut-off value of 151.

CONCLUSION

PAS outperforms USG in the sensitivity of diagnosing appendicitis, whereas USG outperforms PAS in terms of specificity. This study demonstrates the use of PAS in children under 5 years old. Meanwhile, no risk factors were significant in multivariate pediatric acute appendicitis risk factors.

Acute appendicitis and SARS-CoV-2 in children: imaging findings at a tertiary children's hospital during the COVID-19 pandemic

BACKGROUND

Evidence suggests severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection may be associated with appendicitis or clinical symptoms that mimic appendicitis, but it is not clear if the findings or utility of imaging in pediatric patients with suspected appendicitis have changed since the onset of the coronavirus disease 2019 (COVID-19) pandemic.

OBJECTIVE

To evaluate for potential differences in SARS-CoV-2 positive and SARS-CoV-2 negative pediatric patients imaged for suspected appendicitis to determine the reliability of the existing medical imaging approach for appendicitis in a population that contains both SARS-CoV-2 positive and SARS-CoV-2 negative pediatric patients.

MATERIALS AND METHODS

Patients imaged for suspected appendicitis Apr. 1, 2020, to Dec. 31, 2020, were identified via an electronic medical records search. Differences in ultrasound (US) diagnostic performance, use of computed tomography (CT) following US, rates of appendicitis, imaging findings of appendicitis and perforation were compared between SARS-CoV-2 positive and SARS-CoV-2 negative tested patients, using pathology and surgery as reference standards for appendicitis and perforation, respectively. Fisher exact test and Student's t-test were used for statistical analysis.

RESULTS

One thousand, six hundred and ninety-three patients < 18 years old met inclusion criteria, with 46% (772/1,693) female, 11 imaged with only CT and 1,682 with US. Comparing SARS-CoV-2 positive and SARS-CoV-2 negative patients, no statistically significant differences in sensitivity or specificity of US (P = 1 and P = 1, respectively), or in the US (P-values ranging from 0.1 to 1.0) or CT imaging findings (P-values ranging from 0.2 to 1.0) in appendicitis were found. Perforation rates were similar between SARS-CoV-2 positive (20/57, 35.1% perforated) and SARS-CoV-2 negative (359/785, 45.7% perforated) patients with appendicitis (P = 0.13). Use of CT following first-line US was similar, with 7/125 (5.6%) of SARS-CoV-2 positive imaged with CT after US and 127/1,557 (8.2%) of SARS-CoV-2 negative imaged with CT after US (P = 0.39).

CONCLUSION

In pediatric patients with suspected appendicitis, no significant difference was found in the diagnostic performance of US, CT usage or perforation rates between SARS-CoV-2 positive and SARS-CoV-2 negative patients.

Hyponatremia an indicator of complicated appendicitis in children: Starship experience

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.

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

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

An Advanced Nursing Directive for Children With Suspected Appendicitis: Protocol for a Quality Improvement Feasibility Study

Background

Pediatric appendicitis accounts for an estimated 7% to 10% of abdominal pain cases in the emergency department (ED). The diagnosis is time-consuming, and the investigative process depends on physician assessment, resulting in delays in diagnosis and therapeutic management. The utility of an advanced nursing directive (AND) to expedite this process is unclear and needs further exploration.

Objective

This study aims to describe key components of ED flow in patients with suspected appendicitis seen at a pediatric ED and pilot a directive that allows ED nurses to perform an order set that includes blood work, urine tests, analgesics, fluids, and an abdominal-pelvis ultrasound prior to physician assessment.

Methods

This study involves conducting a retrospective chart review alongside a quality improvement initiative to compare key ED flow metrics before and after AND implementation. Primary outcome measures include median time from ED triage assessment to ultrasound completion, analgesia administration, blood work results, and time to disposition (consult or discharge), alongside other key ED flow metrics for suspected appendicitis. Secondary outcomes will involve patient and caretaker satisfaction surveys. Descriptive statistics will be used to summarize the data. For differences in proportions, a chi-square test will be used. The Student t test will be used for continuous variables. A variable-controlled run chart will be performed to assess impact on ED flow metrics. Patient and family satisfaction surveys are administered immediately after the directive encounter and 7 days afterward.

Results

There are currently 3900 patients who have been screened, 344 patients who have been enrolled, and 90 patients who have received the medical directive since implementation in June 2020. Interim results on reduction of time to diagnostic and therapeutic ED flow parameters and satisfaction surveys are expected to be published in February 2022. The final study endpoint will be in June 2022.

Conclusions

This study proposes a novel protocol for improving the diagnosis and treatment of suspected pediatric appendicitis through implementation of an evidence-based AND. This model may provide a standardized, international pathway for management of common pediatric and adult emergencies.

International Registered Report Identifier (IRRID)

RR1-10.2196/33158

Non-operative treatment versus appendectomy for acute uncomplicated appendicitis: A randomized controlled trial

Objectives:

To compare the outcome of non-operative treatment (NOT) with antibiotics versus surgical management of uncomplicated appendicitis in children.

Methods:

This randomized clinical trial (NCT 04030741) was carried out in Pediatric Surgery Department, Mayo Hospital from September 2018 to September 2019. Total sample size was 180, and after informed consent patients were randomly allocated in two groups. All children between 5 and 15 years of age and having pediatric appendicitis score (PAS) >7 were included. Patients with previous abdominal surgery, peritonitis, appendicular mass, or intra-abdominal abscess were excluded. Children in NOT group (Group A) were given intravenous Meropenem and Metronidazole for 48 hours and after starting oral, antibiotics were continued orally for 7 days. In Group B, children underwent appendectomy. Failure of NOT was labeled if there was abscess formation or peri-appendiceal fluid collection on ultrasound, development of peritonitis or recurrence of appendicitis.

Results:

In Group A, mean age was 9.56±1.8 years and in Group B 10.11±1.8 years. There were 123 male and 57 female patients. Group B had 100% successful outcome. NOT (Group A) had successful outcome in 75 patients (83.3%) and failure was noted in 15 (16.7%). Five needed operation within 48 hours, all had appendicolith, and 10 patients presented within 6 months. Raised total leukocyte count (p value < 0.0001) and C reactive protein (p value < 0.04) levels were noted with failure of NOT.

Conclusions:

In this study, success of NOT was 84% so a trial of NOT in cases of uncomplicated appendicitis should be considered in children.

Racial and ethnic disparities in the delayed diagnosis of appendicitis among children

BACKGROUND

Appendicitis is the most common surgical condition in pediatric emergency department (ED) patients. Prompt diagnosis can reduce morbidity, including appendiceal perforation. The goal of this study was to measure racial/ethnic differences in rates of 1) appendiceal perforation, 2) delayed diagnosis of appendicitis, and 3) diagnostic imaging during prior visit(s).

METHODS

This was a 3-year multicenter (seven EDs) retrospective cohort study of children diagnosed with appendicitis using the Pediatric Emergency Care Applied Research Network Registry. Delayed diagnosis was defined as having at least one prior ED visit within 7 days preceding appendicitis diagnosis. We performed multivariable logistic regression to measure associations of race/ethnicity (non-Hispanic [NH]-white, NH-Black, Hispanic, other) with 1) appendiceal perforation, 2) delayed diagnosis of appendicitis, and 3) diagnostic imaging during prior visit(s).

RESULTS

Of 7,298 patients with appendicitis and documented race/ethnicity, 2,567 (35.2%) had appendiceal perforation. In comparison to NH-whites, NH-Black children had higher likelihood of perforation (36.5% vs. 34.9%; adjusted odds ratio [aOR] = 1.21 [95% confidence interval {CI} = 1.01 to 1.45]). A total of 206 (2.8%) had a delayed diagnosis of appendicitis. NH-Black children were more likely to have delayed diagnoses (4.7% vs. 2.0%; aOR = 1.81 [95% CI = 1.09 to 2.98]). Eighty-nine (43.2%) patients with delayed diagnosis had abdominal imaging during their prior visits. In comparison to NH-whites, NH-Black children were less likely to undergo any imaging (28.2% vs. 46.2%; aOR = 0.41 [95% CI = 0.18 to 0.96]) or definitive imaging (e.g., ultrasound/computed tomography/magnetic resonance imaging; 10.3% vs. 35.9%; aOR = 0.15 [95% CI = 0.05 to 0.50]) during prior visits.

CONCLUSIONS

In this multicenter cohort, there were racial disparities in appendiceal perforation. There were also racial disparities in rates of delayed diagnosis of appendicitis and diagnostic imaging during prior ED visits. These disparities in diagnostic imaging may lead to delays in appendicitis diagnosis and, thus, may contribute to higher perforation rates demonstrated among minority children.

Markers of neutrophil activation and extracellular trap formation predict appendicitis

BACKGROUND

Although appendicitis is one of the most frequently occurring pediatric surgery emergencies, current biomarkers for diagnosis are unspecific and have low predictive values. Neutrophils are an essential component of the innate immune system involved during appendicitis. Thus, the current study aimed to evaluate neutrophils and their activation markers in a prospective cohort study.

METHODS

The study population included all children with acute abdominal pain who presented to the pediatric surgery department of 2 large clinics between July 2018 and December 2019. All enrolled subjects underwent blood sample collection with an assessment of white blood cell count, C-reactive protein, cell-free DNA, neutrophil elastase, myeloperoxidase, and citrullinated histone H3. If an appendectomy was performed, the appendix was stained for myeloperoxidase, neutrophil elastase, and citrullinated histone H3 using immunofluorescence.

RESULTS

In total, 198 subjects were included in the study, of whom 133 had histological verified appendicitis. In those with appendicitis, white blood cell count and C-reactive protein showed a moderate diagnostic value for (noncomplicated and complicated) appendicitis. However, cell-free DNA (area under the curve .87) and citrullinated histone H3 (area under the curve .88) demonstrated excellent predictive power for appendicitis. Most notably, citrullinated histone H3 was able to distinguish (1) noncomplicated from complicated appendicitis, and (2) predict patient outcome. Moreover, the examined biomarkers appear to reflect tissue expression and disease severity.

CONCLUSION

Markers of neutrophil activation and extracellular trap formation are excellent biomarkers for appendicitis. In particular, citrullinated histone H3 may be used to identify children with an increased risk of developing complications after appendicitis.

Rare appendiceal escapades in childhood: the Grande experience!

Acute appendicitis in children is known to present in two broad forms: (1) uncomplicated and (2) complicated. Apart from this, a variety of atypical presentations can occur that may pose difficulty in diagnosis or treatment approach. We hereby present a series of such rare experiences namely appendiceal oxyuriasis, sub-hepatic appendicitis and appendiceal mucocele that were encountered and managed accordingly.

The predictors of perforated appendicitis in the pediatric emergency department: A retrospective observational cohort study

OBJECTIVE

Appendiceal perforation has significant effects on perioperative morbidity and postoperative outcome. The present study aimed to identify possible predictive factors associated with perforated appendicitis (PA) in children at admission in the emergency department (ED).

METHODS

In this retrospective observational cohort study, consecutive medical records of children <18 years old with surgically and histopathologically confirmed acute appendicitis (AA) over three years (2013-2015) were analyzed. Patients were divided into two groups: PA and non-perforated appendicitis (NPA). The differences between the two groups and potential predictors of PA were explored using univariate and multivariate analyses.

RESULTS

During the study period, 295 patients underwent an appendectomy and had confirmatory AA diagnoses. Ninety-two patients had a PA (31.2%). In the univariate analysis, male gender, vomiting, diarrhea, fever, elevated white blood cell count (WBC) levels, and high C-reactive protein (CRP) were identified as predictors of PA. In the multivariate analysis, male gender (odds ratio [OR]: 3.133; 95% confidence interval [CI]: 1.610-6.096); vomiting (OR: 2.346; 95% CI: 1.141-4.822); diarrhea (OR: 4.549; 95% CI: 1.850-11.181); fever (OR: 3.429; 95% CI: 1.765-6.663); elevated WBC (OR: 2.962; 95% CI: 1.491-5.884) and elevated CRP (OR: 3.061; 95% CI: 1.267-7.396) were variables that predicted the PA in children.

CONCLUSION

Our data indicate that several clinical and biochemical parameters can reliably distinguish between pediatric PA and NPA at admission in the emergency department.

Delayed presentation and sub-optimal outcomes of pediatric patients with acute appendicitis during the COVID-19 pandemic

OBJECTIVE

Early presentation and prompt diagnosis of acute appendicitis are necessary to prevent progression of disease leading to complicated appendicitis. We hypothesize that patients had a delayed presentation of acute appendicitis during the COVID-19 pandemic, which affected severity of disease on presentation and outcomes.

PATIENTS AND METHODS

We conducted a retrospective review of all patients who were treated for acute appendicitis at Morgan Stanley Children's Hospital (MSCH) between March 1, 2020 and May 31, 2020 when the COVID-19 pandemic was at its peak in New York City (NYC). For comparison, we reviewed patients treated from March 1, 2019 to May 31, 2019, prior to the pandemic. Demographics and baseline patient characteristics were analyzed for potential confounding variables. Outcomes were collected and grouped into those quantifying severity of illness on presentation to our ED, type of treatment, and associated post-treatment outcomes. Fisher's Exact Test and Kruskal-Wallis Test were used for univariate analysis while cox regression with calculation of hazard ratios was used for multivariate analysis.

RESULTS

A total of 89 patients were included in this study, 41 patients were treated for appendicitis from March 1 to May 31 of 2019 (non-pandemic) and 48 were treated during the same time period in 2020 (pandemic). Duration of symptoms prior to presentation to the ED was significantly longer in patients treated in 2020, with a median of 2 days compared to 1 day (p = 0.003). Additionally, these patients were more likely to present with reported fever (52.1% vs 24.4%, p = 0.009) and had a higher heart rate on presentation with a median of 101 beats per minute (bpm) compared to 91 bpm (p = 0.040). Findings of complicated appendicitis on radiographic imaging including suspicion of perforation (41.7% vs 9.8%, p < 0.001) and intra-abdominal abscess (27.1% vs 7.3%, p = 0.025) were higher in patients presenting in 2020. Patients treated during the pandemic had higher rates of non-operative treatment (25.0% vs 7.3%, p = 0.044) requiring increased antibiotic use and image-guided percutaneous drain placement. They also had longer hospital length of stay by a median of 1 day (p = 0.001) and longer duration until symptom resolution by a median of 1 day (p = 0.004). Type of treatment was not a predictor of LOS (HR = 0.565, 95% CI = 0.357-0.894, p = 0.015) or duration until symptom resolution (HR = 0.630, 95% CI = 0.405-0.979, p = 0.040).

CONCLUSION

Patients treated for acute appendicitis at our children's hospital during the peak of the COVID-19 pandemic presented with more severe disease and experienced suboptimal outcomes compared to those who presented during the same time period in 2019.

LEVEL OF EVIDENCE

III.

A Critically Ill Child with Gangrenous Appendicitis Masquerading as Hollow Viscous Perforation

BACKGROUND

Severe complications of acute appendicitis (AA) hitherto well described are less common in clinical practice nowadays. When a septic child is encountered with a short history of abdominal symptoms and disproportionate signs of peritonitis further complicated by radiological findings causing a diagnostic conundrum, management becomes exceedingly demanding. Case Presentation. A 10-year-old previously healthy boy presented to the emergency room with generalized abdominal pain associated with fever and jaundice for a day. Blood workup revealed leucopenia, hyperbilirubinemia, hyponatremia, and elevated CRP. Initial radiological evaluation suggested hollow viscous perforation. He was diagnosed to have hollow viscous perforation peritonitis in severe sepsis. At laparotomy, generalized peritoneal contamination was found, the source of which could be traced down to the gangrenous perforated appendix.

CONCLUSION

Complicated appendicitis, in children, can present with baffling findings. Timely identification of an ill child, adequate workup, prompt resuscitation, and source control are imperative for a successful outcome.

Appendectomy or Not? An Update on the Evidence for Antibiotics Only Versus Surgery for the Treatment of Acute Appendicitis in Children

Appendicitis is a common diagnosis in children being evaluated in the emergency department. After diagnosis, standard treatment has been surgical appendectomy; however, in recent years there is a growing body of evidence evaluating the possibility of nonoperative management in both children and adults. This review will present the current state of the pediatric literature that suggests patients may be successfully treated with antibiotics alone (ie, without surgery), but that a proportion of these patients will have recurrent appendicitis. Given that the literature regarding the option of antibiotic-only management compared with surgery is not yet definitive, there are many factors for providers to discuss with families and patients when considering treatment for acute appendicitis.

A Rare Complication of Henoch-Schönlein Purpura: Acute Appendicitis Treated Conservatively – A Case Report and Literature Review

Henoch-Schönlein purpura (HSP) is the most common systemic vasculitis of childhood. It is a self-limiting disorder of unknown autoimmune origin. It affects multiple organ systems including the skin, joints, the gastrointestinal (GI) system, and the kidneys. GI symptoms include abdominal pain, nausea, vomiting, GI bleeding and intussusception. Acute appendicitis is an extremely rare complication of HSP. When it does occur, physicians seem to rush for surgical management. However, we suggest that conservative management should be the first approach to treatment, but great caution has to be paid to the small, yet possible risk of perforation of the appendix. Here, we present a case of an 8-year-old girl, who was admitted and diagnosed with HSP. On the second day of admission, the patient developed right iliac fossa pain and tenderness, as well as seven episodes of vomiting. She was diagnosed clinically with acute appendicitis which was confirmed by abdominal ultrasound. The patient was treated successfully with conservative management without any complication.

Management of complicated acute appendicitis in children: Still an existing controversy

Complicated acute appendicitis (CAA) is a serious condition and carries significant morbidity in children. A strict diagnosis is challenging, as there are many lesions that mimic CAA. The management of CAA is still controversial. There are two options for treatment: Immediate operative management and non-operative management with antibiotics and/or drainage of any abscess or phlegmon. Each method of treatment has advantages and disadvantages. Operative management may be difficult due to the presence of inflamed tissues and may lead to detrimental events. In many cases, non-operative management with or without drainage and interval appendectomy is advised. The reasons for this approach include new medications and policies for the use of antibiotic therapy. Furthermore, advances in radiological interventions may overcome difficulties such as diagnosing and managing the complications of CAA without any surgeries. However, questions have been raised about the risk of recurrence, prolonged use of antibiotics, lengthened hospital stay and delay in returning to daily activities. Moreover, the need for interval appendectomy is currently under debate because of the low risk of recurrence. Due to the paucity of high-quality studies, more randomized controlled trials to determine the precise management strategy are needed. This review aims to study the current data on operative vs non-operative management for CAA in children and to extract any useful information from the literature.

Hyponatremia as a marker of complicated appendicitis: A systematic review

BACKGROUND

Acute appendicitis, the most common cause of acute surgical abdomen, is associated with intra-abdominal complications, such as perforation, that increase morbidity and mortality. Early and accurate preoperative diagnosis of complicated appendicitis mandates the identification of new diagnostic markers. This systematic review summarizes current literature on the adoption of hyponatremia as an early diagnostic and predictive marker of complicated appendicitis.

METHODS

Pubmed, Cochrane Library, Scopus, Google Scholar, WHO Global Health Library, System for Information on Grey Literature, ISI Web of Science, EBSCOHost and Virtual Health Library were searched in accordance with the PRISMA guidelines in order to identify original human studies investigating the association between hyponatremia and the presence or development of complicated appendicitis.

RESULTS

A total of 7 studies conducted in 6 different countries were identified. A prospective diagnostic accuracy study reported a strong association between hyponatremia and complicated appendicitis in children. The largest sample size study performed in adults reported a significant association between hyponatremia and perforated or gangrenous appendicitis.

CONCLUSIONS

The admission serum sodium level measurement, a routinely performed, low-cost test, should be taken into account in patients with clinical presentation compatible with acute appendicitis and suspicion of underlying complications. Future well-designed prospective diagnostic accuracy studies are required to further establish the association between hyponatremia and perforated appendicitis.

Bayesian Approach to Predicting Acute Appendicitis Using Ultrasonographic and Clinical Variables in Children

Objectives

Ultrasound has an established role in the diagnostic pathway for children with suspected appendicitis. Relevant clinical information can influence the diagnostic probability and reporting of ultrasound findings. A Bayesian network (BN) is a directed acyclic graph (DAG) representing variables as nodes connected by directional arrows permitting visualisation of their relationships. This research developed a BN model with ultrasonographic and clinical variables to predict acute appendicitis in children.

Methods

A DAG was designed through a hybrid method based on expert opinion and a review of literature to define the model structure; and the discretisation and weighting of identified variables were calculated using principal components analysis, which also informed the conditional probability table of nodes.

Results

The acute appendicitis target node was designated as an outcome of interest influenced by four sub-models, including Ultrasound Index, Clinical History, Physical Assessment, and Diagnostic Tests. These sub-models included four sonographic, three blood-test, and six clinical variables. The BN was scenario tested and evaluated for face, predictive, and content validity. A lack of similar networks complicated concurrent and convergent validity evaluation.

Conclusions

To our knowledge, this is the first BN model developed for the identification of acute appendicitis incorporating imaging variables. It has particular benefit for cases in which variables are missing because prior probabilities are built into corresponding nodes. It will be of use to clinicians involved in ultrasound examination of children with suspected appendicitis, as well as their treating clinicians. Prospective evaluation and development of an online tool will permit validation and refinement of the BN.