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Nemeh C, Hassan IN, Walsh A, Iyer S, Gitzelmann CA. Pediatric Ultrasound Appendicitis Score for the Diagnosis of Acute Appendicitis to Reduce Computed Tomography Scan Utilization. Am Surg 2024; 90:245-251. [PMID: 37651539 DOI: 10.1177/00031348231199172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
Abstract
BACKGROUND Acute appendicitis is one of the most common reasons for pediatric surgical consultation in the emergency room. Although acute appendicitis is a clinical diagnosis, the use of imaging in the emergency department to assist with the diagnosis is very common. Ultrasound is frequently utilized in pediatrics because of the radiation risks associated with computed tomography (CT) scan. The risks of radiation in the pediatric population are much more significant than in adults. Reasons for this include smaller size so there is a relative higher radiation dose than for larger adults, radiosensitive organs such as thyroid, bone marrow, and gonads, and radiation exposure earlier in life allows for more time that a radiation induced cancer could develop. The risks of radiation from imaging are increased with cumulative dosing. METHODS The purpose of this study was to incorporate the pediatric appendicitis score (PAS) and standardized ultrasound scoring system to provide a combined score that would assist with the clinical diagnosis of acute appendicitis and avoid the need for a CT scan. RESULTS The presented data shows that for scores of 7 or more, the specificity and sensitivity is 90% and 90.2%, respectively for the diagnosis of acute appendicitis. DISCUSSION This study validates the combined score, shows the specific cutoffs, and initiates the discussion that CT scan may not always be required for diagnosing acute appendicitis if this scoring system is used.
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Affiliation(s)
- Christopher Nemeh
- Department of General Surgery, Rutgers-New Jersey Medical School, Newark, NJ, USA
| | - Irfan N Hassan
- Department of Radiology, Cooperman Barnabas Medical Center, Livingston, NJ, USA
| | - Abigail Walsh
- Division of Pediatric Surgery, Robert Wood Johnson Medical School, Cooperman Barnabas Medical Center, Livingston, NJ, USA
| | - Sekhar Iyer
- Department of Radiology, Cooperman Barnabas Medical Center, Livingston, NJ, USA
| | - Christopher A Gitzelmann
- Division of Pediatric Surgery, Robert Wood Johnson Medical School, Cooperman Barnabas Medical Center, Livingston, NJ, USA
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2
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Jiang F. Physicians Should Pay Attention to Signs. Pediatr Emerg Care 2024; 40:e2. [PMID: 38123143 DOI: 10.1097/pec.0000000000003100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2023]
Affiliation(s)
- Fenglin Jiang
- Department of Medical Ultrasound Yanbian University Hospital Yanji, Jilin China
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Lamm R, Kumar SS, Collings AT, Haskins IN, Abou-Setta A, Narula N, Nepal P, Hanna NM, Athanasiadis DI, Scholz S, Bradley JF, Train AT, Pucher PH, Quinteros F, Slater B. Diagnosis and treatment of appendicitis: systematic review and meta-analysis. Surg Endosc 2023; 37:8933-8990. [PMID: 37914953 DOI: 10.1007/s00464-023-10456-5] [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: 08/18/2023] [Accepted: 09/07/2023] [Indexed: 11/03/2023]
Abstract
BACKGROUND The optimal diagnosis and treatment of appendicitis remains controversial. This systematic review details the evidence and current best practices for the evaluation and management of uncomplicated and complicated appendicitis in adults and children. METHODS Eight questions regarding the diagnosis and management of appendicitis were formulated. PubMed, Embase, CINAHL, Cochrane and clinicaltrials.gov/NLM were queried for articles published from 2010 to 2022 with key words related to at least one question. Randomized and non-randomized studies were included. Two reviewers screened each publication for eligibility and then extracted data from eligible studies. Random effects meta-analyses were performed on all quantitative data. The quality of randomized and non-randomized studies was assessed using the Cochrane Risk of Bias 2.0 or Newcastle Ottawa Scale, respectively. RESULTS 2792 studies were screened and 261 were included. Most had a high risk of bias. Computerized tomography scan yielded the highest sensitivity (> 80%) and specificity (> 93%) in the adult population, although high variability existed. In adults with uncomplicated appendicitis, non-operative management resulted in higher odds of readmission (OR 6.10) and need for operation (OR 20.09), but less time to return to work/school (SMD - 1.78). In pediatric patients with uncomplicated appendicitis, non-operative management also resulted in higher odds of need for operation (OR 38.31). In adult patients with complicated appendicitis, there were higher odds of need for operation following antibiotic treatment only (OR 29.00), while pediatric patients had higher odds of abscess formation (OR 2.23). In pediatric patients undergoing appendectomy for complicated appendicitis, higher risk of reoperation at any time point was observed in patients who had drains placed at the time of operation (RR 2.04). CONCLUSIONS This review demonstrates the diagnosis and treatment of appendicitis remains nuanced. A personalized approach and appropriate patient selection remain key to treatment success. Further research on controversies in treatment would be useful for optimal management.
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Affiliation(s)
- Ryan Lamm
- Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Sunjay S Kumar
- Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA.
- Thomas Jefferson University, 1015 Walnut Street, 613 Curtis, Philadelphia, PA, 19107, USA.
| | - Amelia T Collings
- Hiram C. Polk, Jr Department of Surgery, University of Louisville, Louisville, KY, USA
| | - Ivy N Haskins
- Department of Surgery, University of Nebraska Medical Center, Omaha, NE, USA
| | - Ahmed Abou-Setta
- Centre for Healthcare Innovation, University of Manitoba, Winnipeg, MB, Canada
| | - Nisha Narula
- Department of Surgery, Rutgers, New Jersey Medical School, Newark, NJ, USA
| | - Pramod Nepal
- Division of Colon and Rectal Surgery, University of Illinois at Chicago, Chicago, IL, USA
| | - Nader M Hanna
- Department of Surgery, Queen's University, Kingston, ON, Canada
| | | | - Stefan Scholz
- Division of General and Thoracic Pediatric Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Joel F Bradley
- Division of General Surgery, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Arianne T Train
- Department of Surgery, Penn Medicine Lancaster General Health, Lancaster, PA, USA
| | - Philip H Pucher
- Department of Surgery, Queen Alexandra Hospital, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - Francisco Quinteros
- Division of Colorectal Surgery, Advocate Lutheran General Hospital, Park Ridge, IL, USA
| | - Bethany Slater
- Division of Pediatric Surgery, University of Chicago Medicine, Chicago, IL, USA
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Raeisi R, Azizi M, Amiri J, Ghorbanpour M, Esna-Ashari F. Accuracy Evaluation of Pediatric Appendicitis Scoring (PAS) Method in Differentiating Nonspecific Abdominal Pain from Appendicitis. Int J Prev Med 2023; 14:40. [PMID: 37351062 PMCID: PMC10284213 DOI: 10.4103/ijpvm.ijpvm_539_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2021] [Accepted: 10/27/2022] [Indexed: 06/24/2023] Open
Abstract
Background This study aimed at evaluating the accuracy of the pediatric appendicitis scoring method in differentiating nonspecific abdominal pain (NSAP) from appendicitis. Methods This cross-sectional study was conducted on 391 children who were hospitalized in the emergency ward due to acute abdominal pain suspected of appendicitis . Pediatric Appendicitis Score (PAS), C-reactive protein (CRP), and appendicitis pathology results of patients undergoing surgery were recorded. Results The results showed that the no significant difference was found among patients in the three experimental groups (appendicitis, specific abdominal pain except appendicitis, and NSAP) with respect to temperature (p = 0.212), but the other variables were significantly different. Findings showed that high CRP frequency, pain migration to right lower quadrant (RLQ), tenderness in right iliac fossa (RIF), anorexia, leukocytosis, high neutrophil, and mean tenderness in RLQ in the appendicitis group were higher than those in the other two groups (p = 0.001). The PAS questionnaire can also be used as a reliable questionnaire with appropriate sensitivity (0.929) and specificity (0.993), and this questionnaire along with detailed clinical examinations could reduce the rate of negative appendectomy to less than 1%. Conclusions This study showed high accuracy of PAS in diagnosing children with appendicitis and differentiating appendicitis from cases of NSAP and specific abdominal pain other than appendicitis. The PAS system could also significantly reduce cases of negative appendicitis. Although high CRP had an excellent ability to diagnose appendicitis, its accuracy was lower than PAS.
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Affiliation(s)
- Roya Raeisi
- Department of Pediatrics, Hamadan University of Medical Sciences, Hamadan, Iran
| | - Mona Azizi
- Department of Pediatrics, Hamadan University of Medical Sciences, Hamadan, Iran
| | - Jalaleddin Amiri
- Department of Pediatrics, Hamadan University of Medical Sciences, Hamadan, Iran
| | | | - Farzaneh Esna-Ashari
- Community Medicine, Faculty of Medicine, Hamadan University of Medical Sciences, Hamadan, Iran
- School of Public Health and Research Center for Health Sciences, Hamadan University of Medical Sciences, Hamadan, Iran
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Pediatric Appendicitis Score for Identifying Acute Appendicitis in Children Presenting With Acute Abdominal Pain to the Emergency Department. Indian Pediatr 2022. [DOI: 10.1007/s13312-022-2620-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Abdominal and Thoracic Imaging Features in Children with MIS-C. GASTROENTEROLOGY INSIGHTS 2022. [DOI: 10.3390/gastroent13040032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
(1) Background: Currently, multisystem inflammatory syndrome in children (MIS-C) is diagnosed based on clinical symptoms and laboratory findings of inflammation in the body. Once MIS-C is diagnosed, children will need to be followed over time. The imaging modalities most commonly used in the evaluation of patients with MIS-C include radiographs, ultrasound (US), and computed tomography (CT). Our study aims to summarise the literature data for the main gastrointestinal and pulmonary imaging features in children diagnosed with MIS-C and to share a single-centre experience. (2) Methods: We present the imaging findings in a cohort of 51 children diagnosed with MIS-C, admitted between December 2020 and February 2022. Imaging studies include chest and abdominal radiographs, thoracic, abdominal, and neck US and echocardiography (ECHO), and CT of the chest, abdomen, and pelvis. (3) Results: In accordance with the results in other studies, our observations show predominantly gastrointestinal involvement (GI) with ascites (33/51, 65%) and lymphadenopathy (19/51, 37%), ileitis or colitis (18/51, 35%), some cases of splenomegaly (9/51, 18%), hepatomegaly (8/51, 16%), and a few cases of renal enlargement (3/51, 6%) and gallbladder fossa oedema/wall thickening (2/51, 4%). Most common among the thoracic findings are posterior–basal consolidations (16/51, 31%), pleural effusion (14/51, 27%), and ground-glass opacities (12/51, 24%). We also register the significant involvement of the cardiovascular system with pericarditis (30/51, 58%), pericardial effusion (16/51, 31%), and myocarditis (6/51, 12%). (4) Conclusions: Radiologists should be aware of those imaging findings in order to take an important and active role not only in applying an accurate diagnosis, but also in the subsequent management of children with MIS-C. Radiological findings are not the primary diagnostic tool, but can assist in the evaluation of the affected systems and guide treatment.
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Nassiri AM, Pruden RD, Holan CA, Guerra AD, Nganga PW, Wilkinson MH, Lawson KA, Allen CH, Gregg VS, Naiditch JA. Pediatric appendicitis in the time of the COVID-19 pandemic: A retrospective chart review. J Am Coll Emerg Physicians Open 2022; 3:e12722. [PMID: 35462960 PMCID: PMC9019144 DOI: 10.1002/emp2.12722] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Revised: 03/17/2022] [Accepted: 03/24/2022] [Indexed: 11/23/2022] Open
Abstract
Aim Conduct a time trend analysis that describes 2 groups of patients admitted to a large tertiary children's hospital that presented with appendicitis and determine if there was an increase in complicated appendicitis when compared between 2 time periods before and during the early coronavirus disease 2019 (COVID‐19) pandemic of 2020. Methods We conducted a retrospective analysis of all children presenting to a single‐center site with appendicitis between March 23 and August 31, 2020, in the Central Texas region. We compared 507 patients presenting with appendicitis from the non‐COVID‐19 era in 2019 with n = 249 to patients presenting during the COVID time period with n = 258. All patients with appendicitis within those time periods were reviewed with analysis of various characteristics in regard to presentation, diagnosis of uncomplicated versus complicated appendicitis, and management outcomes. Results There were no significant demographic differences or change in the number of appendicitis cases noted between the 2 time periods of comparison. There was no significant difference in rates of complicated appendicitis or presentation time following symptom onset between the 2 eras. There was no significant difference in intraoperative or postoperative complications. There was a statistically significant increase in the use of computed tomography (CT) scans (P‐value = 0.004) with patients 1.81 times more likely to have a CT scan in the pandemic era after adjusting for patient‐level factors. The effect of severe acute respiratory syndrome coronavirus 2 status on outcomes was not part of the data analysis. Conclusion Our study is the largest to date examining appendicitis complications in the era of COVID. In the time of the COVID‐19 pandemic, we found no delay in presentation in children presenting to the emergency department and no increase in complicated appendicitis. We did identify an increase in the use of CT scans for definitive diagnosis of appendicitis noted in the pandemic era. Although COVID‐19 status was not studied, the finding of increased CT use for a definitive diagnosis of appendicitis was a distinctive finding of this study showing a change in practice in pediatric emergency medicine.
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Affiliation(s)
- Arianna M Nassiri
- Department of Pediatric Emergency Medicine Dell Children's Medical Center Austin Texas USA
| | - Roy D Pruden
- Department of Pediatrics Dell Children's Medical Center Austin Texas USA
| | - Cole A Holan
- University of Texas Dell Medical School Austin Texas USA
| | | | - Peris W Nganga
- Department of Pediatrics Dell Children's Medical Center Austin Texas USA
| | - Matthew H Wilkinson
- Department of Pediatric Emergency Medicine Dell Children's Medical Center Austin Texas USA
| | - Karla A Lawson
- Department of Surgery and Perioperative Care Division of Pediatric Surgery Dell Children's Medical Center University of Texas Austin Texas USA
| | - Coburn H Allen
- Department of Pediatric Emergency Medicine Dell Children's Medical Center Austin Texas USA
| | - Victoria S Gregg
- Department of Pediatric Emergency Medicine Dell Children's Medical Center Austin Texas USA
| | - Jessica A Naiditch
- Department of Surgery and Perioperative Care Division of Pediatric Surgery Dell Children's Medical Center University of Texas Austin Texas USA
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Zisman A, Novi B, Gaughan J, Carr L. Factors affecting utilization of CT scan following ultrasound evaluation of suspected appendicitis. J Osteopath Med 2022; 122:313-318. [PMID: 35245969 DOI: 10.1515/jom-2021-0251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Accepted: 01/13/2022] [Indexed: 11/15/2022]
Abstract
CONTEXT When evaluating a pediatric patient in the emergency department for suspected appendicitis, a provider is often faced with the dilemma of deciding if a computed tomography (CT) scan is warranted when-as is most often the case-ultrasound results do not yield a definitive diagnosis. The potential risks of radiation must be weighed against numerous aspects of a patient's background, physical exam, and already-obtained workup. OBJECTIVES This study aims to aid in future decision making of providers in their evaluation of patients with suspected appendicitis, to help facilitate a more comprehensive answer to the "next-steps" in the question of equivocal ultrasound, and to create a pathway utilizing lab results, physical exam findings, and pertinent positives and negatives in patient history to facilitate a more objective decision-making process for ordering a CT scan. METHODS A retrospective chart review was performed for patients who were evaluated for possible appendicitis at our institution between October 2016 and October 2017 and whose ultrasound results were equivocal. We determined what factors led to increased frequency of obtaining CT scans. RESULTS Statistical analysis showed that several factors were independently associated with the increased likelihood of having a CT scan performed. When considered in combination with the other parameters, it was found that older children, males, report of right lower quadrant (RLQ) pain, and presence of RLQ tenderness on physical exam were all associated with a significantly higher likelihood of having a CT scan performed. CONCLUSIONS When combined with present algorithms and protocols already in use, this information can assist the provider in making prudent decisions for their patients with the potential for reduced provider bias.
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Affiliation(s)
- Adam Zisman
- Department of Pediatrics, St. Christopher's Hospital for Children, Philadelphia, PA, USA
| | - Brian Novi
- Department of Pediatrics, St. Christopher's Hospital for Children, Philadelphia, PA, USA.,St. Christopher's Hospital for Children, Philadelphia, PA, USA
| | - John Gaughan
- Lewis Katz School of Medicine, Temple University, Philadelphia, PA, USA
| | - Lauren Carr
- Department of Pediatrics, St. Christopher's Hospital for Children, Philadelphia, PA, USA
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Salim J, Agustina F, Maker JJR. Pre-Coronavirus Disease 2019 Pediatric Acute Appendicitis: Risk Factors Model and Diagnosis Modality in a Developing Low-Income Country. Pediatr Gastroenterol Hepatol Nutr 2022; 25:30-40. [PMID: 35087731 PMCID: PMC8762600 DOI: 10.5223/pghn.2022.25.1.30] [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: 08/04/2021] [Revised: 09/21/2021] [Accepted: 10/03/2021] [Indexed: 11/22/2022] Open
Abstract
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.
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Affiliation(s)
- Jonathan Salim
- Faculty of Medicine, Pelita Harapan University, Tangerang, Indonesia
| | - Flora Agustina
- Faculty of Medicine, Pelita Harapan University, Tangerang, Indonesia.,Pediatric Surgery Department, Siloam Hospitals Lippo Village, Tangerang, Indonesia
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Determining the impact of body mass index on ultrasound accuracy for diagnosing appendicitis: Is it less useful in obese children? J Pediatr Surg 2021; 56:2010-2015. [PMID: 33573804 DOI: 10.1016/j.jpedsurg.2021.01.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Revised: 01/05/2021] [Accepted: 01/15/2021] [Indexed: 11/20/2022]
Abstract
BACKGROUND Ultrasonography (US) is the preferred imaging for suspected pediatric appendicitis. We hypothesize that children with elevated Body-Mass-Index-for-age percentile (BMIP) may be more likely to have an inaccurate or equivocal (IE) US. METHODS After IRB approval, a four-year review was performed on pediatric patients evaluated for appendicitis by US. The CDC BMIP Calculator was used. IE subgroups were analyzed together for comparison against the accurate group. RESULTS 1059 patients were included: median age 11.3 years (IQR: 8.2, 14.6), 506 (47.8%) males. Median BMIP was 65.9 (IQR: 33.9, 89.6). US accurately diagnosed 857 (80.9%), incorrectly diagnosed 76 (7.2%), 126 (11.9%) were equivocal. Overall sensitivity was 0.85, specificity 0.96, PPV 0.93 and NPV 0.91. Obese children (BMIP ≥95%), had higher odds of IE US (OR: 1.86, 95% CI: 1.28, 2.70; p = 0.001). When analyzed by sex, risk increased in obese males (OR: 2.55, 95% CI:1.53, 4.24; p = 0.0003) but normalized in obese females (OR: 1.30, 95% CI:0.74, 2.28; p = 0.35). CONCLUSIONS An elevated BMIP may increase difficulty in visualizing the appendix, resulting in inaccurate or equivocal findings. This risk is seen specifically in obese males. If US findings do not correlate with clinical assessment in obese children with abdominal pain, further evaluation may be warranted.
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Tunc E, Fraundorf E, Worley S, Aquino M, Magnuson D, Lampl BS, Jennings S, Fertel BS. The use of a pediatric appendicitis pathway in a large integrated health system reduced computed tomography imaging in the ED. Am J Emerg Med 2021; 50:211-217. [PMID: 34392140 DOI: 10.1016/j.ajem.2021.07.064] [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: 01/11/2021] [Revised: 07/27/2021] [Accepted: 07/31/2021] [Indexed: 10/20/2022] Open
Abstract
BACKGROUND Appendicitis is the most common cause of an acute surgical abdomen in children. Diagnosis is often challenging as few pediatric patients present with classic symptoms. Clinicians are thus dependent on imaging to reach an accurate diagnosis. Although computerized tomography (CT) has high sensitivity and specificity, it has the disadvantage of imparting ionizing radiation. Ultrasound (US) is readily available and has comparable accuracy to CT when performed by experienced sonographers. We sought to examine the impact of a system-wide process improvement plan on CT use and other metrics in pediatric patients who presented to the Emergency Department (ED) with suspected appendicitis. METHODS This is a retrospective study of the impact of a Pediatric Appendicitis Pathway (PAP) within a large integrated hospital system with 12 EDs including 3 designated hub EDs. Patients were placed in an initial risk category utilizing the Pediatric Appendicitis Score (PAS), and received US of the appendix at a hub ED if indicated by the PAS. Patients presenting to community EDs who required US appendix were transferred to hub EDs for imaging. Patients presenting in the 6-month pre-implementation period were compared to patients presenting in a 14-month post-implementation period on CT and US utilization, negative and missed appendectomy rates, and ED length of stay (LOS). RESULTS 1874 patients (401 pre-PAP and 1473 post-PAP) were included in the study. At the hub EDs the rate of CT imaging for suspected appendicitis was reduced from 31% to 17% with a resultant increase in US utilization from 83% (333/401) to 90% (1331/1473) (p < 0.001). At community general EDs (404 pre-PAP and 449 post-PAP), the rate of CT was decreased from 45% (181/404) to 32%(144/449) (p < 0.001)) There was no significant change in the negative appendectomy rate pre-PAP (1/59 = 1.7%) and post-PAP (4/168 = 2.4%) (p = 0.99) at the hub EDs. There were no missed appendicitis cases after PAP implementation compared to 1 case in the pre-PAP period. Overall LOS was similar pre and post-PAP, however LOS was longer in patients that required transfer from community general EDs to hub EDs (median 264 vs 342 min, p < 0.001). CONCLUSIONS A PAP that stratified patients into risk groups using the PAS and encouraged the use of US as a first line imaging modality, reduced the number of CT performed in a large integrated health system without significant changes to clinical outcomes. Furthermore, transferring select patients for an US as opposed to obtaining an initial CT in community general EDs was feasible and reduced CT use in the pediatric population.
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Affiliation(s)
- Emine Tunc
- Department of Pediatrics, University of Washington, Seattle, WA, United States of America
| | - Erika Fraundorf
- Division of Pediatric Emergency Medicine, Emergency Services Institute, Cleveland Clinic Health System and Lerner College of Medicine in Cleveland Ohio, United States of America
| | - Sarah Worley
- Department of Quantitative Health Sciences, Cleveland Clinic Health System and Lerner College of Medicine in Cleveland Ohio, United States of America
| | - Michael Aquino
- Division of Pediatric Radiology, Imaging Institute, Cleveland Clinic Health System and Lerner College of Medicine in Cleveland Ohio, United States of America
| | - David Magnuson
- Division of Pediatric Surgery, Digestive Disease Institute, Cleveland Clinic Health System and Lerner College of Medicine in Cleveland Ohio, United States of America
| | - Brooke S Lampl
- Division of Pediatric Radiology, Imaging Institute, Cleveland Clinic Health System and Lerner College of Medicine in Cleveland Ohio, United States of America
| | - Stephanie Jennings
- Division of Pediatric Hospital Medicine, Pediatric Institute, Cleveland Clinic Health System and Lerner College of Medicine in Cleveland Ohio, United States of America
| | - Baruch S Fertel
- Emergency Services Institute and Enterprise Quality and Safety, Cleveland Clinic Health System and Lerner College of Medicine in Cleveland Ohio, United States of America.
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Harwood R, Partridge R, Minford J, Almond S. Paediatric abdominal pain in the time of COVID-19: a new diagnostic dilemma. J Surg Case Rep 2020; 2020:rjaa337. [PMID: 32994918 PMCID: PMC7505408 DOI: 10.1093/jscr/rjaa337] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Accepted: 08/27/2020] [Indexed: 01/11/2023] Open
Abstract
The diagnostic uncertainty for children with abdominal pain has increased during the COVID-19 pandemic with the additional consideration of both COVID-19 and paediatric inflammatory multisystem syndrome—temporally associated with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (PIMS-TS) alongside appendicitis, mesenteric adenitis and other less common causes of abdominal pain. We describe the cases of two children who presented with severe abdominal pain, non-bilious vomiting and high temperatures during the UK’s first peak of the COVID-19 pandemic. Laboratory and abdominal ultrasound features were similar for both children but symptom progression in combination with cross-sectional abdominal imaging enabled differentiation between PIMS-TS and appendicitis with concurrent COVID-19. These cases highlight the importance of regular clinical review, multidisciplinary working and the utility of early cross-sectional imaging to determine the underlying condition.
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Affiliation(s)
- Rachel Harwood
- Department of Paediatric Surgery, Alder Hey in the Park, Liverpool, UK
| | - Roland Partridge
- Department of Paediatric Surgery, Alder Hey in the Park, Liverpool, UK
| | - Joanne Minford
- Department of Paediatric Surgery, Alder Hey in the Park, Liverpool, UK
| | - Sarah Almond
- Department of Paediatric Surgery, Alder Hey in the Park, Liverpool, UK
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Kim I, Kwon H, Choi YJ, Kwak YH, Lee JH, Suh D, Jung JY, Park JW. Computed tomography scan usage when US results are non-diagnostic for suspected acute appendicitis in children. Medicine (Baltimore) 2020; 99:e21961. [PMID: 32899032 PMCID: PMC7478412 DOI: 10.1097/md.0000000000021961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
This retrospective study was aimed to determine the factors suggesting the need for computed tomography (CT) scanning when ultrasound (US) imaging results are negative or non-diagnostic in children suspicious for acute appendicitis in the emergency department.Patients less than 18 years old who underwent abdominal ultrasound and CT to rule out acute appendicitis were enrolled. Patients were classified into 2 groups: the false-negative group, in which patients had negative or non-diagnostic results on the initial US and a final diagnosis of acute appendicitis on the following abdominal CT, and the true-negative group, in which patients had negative or non-diagnostic US results and were negative on abdominal CT. Logistic regression and propensity score matching with the predicting factors were performed.The presence of vomiting (odds ratio (OR), 7.78; 95% confidence interval (CI), 1.92-41.04) and poor oral intake (OR, 4.67; 95% CI, 1.21-21.15) with a high white blood cell (WBC) count (OR 1.26; 95% CI, 1.09-2.37), segmented neutrophil ratio (OR, 1.09; 95% CI, 1.03-1.16), and C-reactive protein (CRP) (OR, 1.49; 95% CI, 1.09-2.37) were suggestive of the false-negative group. The propensity-matched population also showed significant associations with vomiting (OR, 7.86; 95% CI, 1.65-37.40) and poor oral intake (OR, 5.50; 95% CI, 1.28-23.69) with an elevated WBC count (OR, 1.27; 95% CI, 1.08-1.50), segmented neutrophil ratio (OR, 1.09; 95% CI, 1.03-1.16), and CRP (OR, 1.51; 95% CI, 1.03-2.22).A CT scan should be considered in children with suspected acute appendicitis if they have vomiting, high CRP, and high WBC count, despite negative or non-diagnostic US results.
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Affiliation(s)
- Injoon Kim
- Department of Emergency Medicine, Seoul National University Hospital, Seoul
| | - Hyuksool Kwon
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Seongnam
| | - Yoo Jin Choi
- Department of Emergency Medicine, Ajou University School of Medicine, Suwon, Republic of Korea
| | - Young Ho Kwak
- Department of Emergency Medicine, Seoul National University Hospital, Seoul
| | - Jin Hee Lee
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Seongnam
| | - Dongbum Suh
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Seongnam
| | - Jae Yun Jung
- Department of Emergency Medicine, Seoul National University Hospital, Seoul
| | - Joong Wan Park
- Department of Emergency Medicine, Seoul National University Hospital, Seoul
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14
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Conwell NK, Kennedy NJ, Quinton AE. Diagnostic performance of ultrasound to differentiate perforated from non‐perforated paediatric appendicitis: A narrative review. SONOGRAPHY 2020. [DOI: 10.1002/sono.12232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- Nancy K. Conwell
- Department of Medical Imaging Toowoomba Hospital South Toowoomba Queensland Australia
| | - Narelle J. Kennedy
- Discipline of Obstetrics, Gynaecology and Neonatology, Sydney Medical School Nepean University of Sydney, Nepean Hospital Penrith New South Wales Australia
- Christopher Kohlenberg Department of Perinatal Ultrasound Nepean Hospital Penrith New South Wales Australia
| | - Ann E. Quinton
- Discipline of Obstetrics, Gynaecology and Neonatology, Sydney Medical School Nepean University of Sydney, Nepean Hospital Penrith New South Wales Australia
- Medical Sonography, School of Health, Medical and Applied Science, Central Queensland University Sydney New South Wales Australia
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15
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Guaitoli E, Gallo G, Cardone E, Conti L, Famularo S, Formisano G, Galli F, Giuliani G, Martino A, Pasculli A, Patini R, Soriero D, Pappalardo V, Casoni Pattacini G, Sparavigna M, Meniconi R, Mazzari A, Barra F, Orsenigo E, Pertile D. Consensus Statement of the Italian Polispecialistic Society of Young Surgeons (SPIGC): Diagnosis and Treatment of Acute Appendicitis. J INVEST SURG 2020; 34:1089-1103. [PMID: 32167385 DOI: 10.1080/08941939.2020.1740360] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Background: Acute appendicitis (AA) is one of the most common causes of abdominal pain requiring surgical intervention. Approximately 20% of AA cases are characterized by complications such as gangrene, abscesses, perforation, or diffuse peritonitis, which increase patients' morbidity and mortality. Diagnosis of AA can be difficult, and evaluation of clinical signs, laboratory index and imaging should be part of the management of patients with suspicion of AA.Methods: This consensus statement was written in relation to the most recent evidence for diagnosis and treatment of AA, performing a literature review on the most largely adopted scientific sources. The members of the SPIGC (Italian Polispecialistic Society of Young Surgeons) worked jointly to draft it. The recommendations were defined and graded based on the current levels of evidence and in accordance with the criteria adopted by the American College of Chest Physicians (CHEST) for the strength of the recommendations.Results: Fever and migratory pain tend to be present in patients with suspicion of AA. Laboratory and radiological examinations are commonly employed in the clinical practice, but today also scoring systems based on clinical signs and laboratory data have slowly been adopted for diagnostic purpose. The clinical presentation of AA in children, pregnant and elderly patients can be unusual, leading to more difficult and delayed diagnosis. Surgery is the best option in case of complicated AA, whereas it is not mandatory in case of uncomplicated AA. Laparoscopic surgical treatment is feasible and recommended. Postoperative antibiotic treatment is recommended only in patients with complicated AA.
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Affiliation(s)
| | - Gaetano Gallo
- Department of Medical and Surgical Sciences, University of Catanzaro, Catanzaro, Italy
| | - Eleonora Cardone
- Department of Surgery, Santa Maria del Popolo degli Incurabili Hospital, Napoli, Italy
| | - Luigi Conti
- Department of Surgery, G. Da Saliceto Hospital, Piacenza, Italy
| | - Simone Famularo
- Department of Medicine and Surgery University of Milan Bicocca HPB Unit, San Gerardo Hospital, Monza, Italy
| | - Giampaolo Formisano
- Department of General and Minimally Invasive Surgery, Misericordia Hospital, Grosseto, Italy
| | | | - Giuseppe Giuliani
- Department of General and Minimally Invasive Surgery, Misericordia Hospital, Grosseto, Italy
| | - Antonio Martino
- Department of General Surgery, University of Genoa, Genova, Italy
| | | | - Romeo Patini
- Odontostomatology and Oral Surgery, Sacro Cuore Hospital, Rome, Italy
| | - Domenico Soriero
- Department of General Surgery, University of Genoa, Genova, Italy
| | | | | | - Marco Sparavigna
- Department of General Surgery, University of Genoa, Genova, Italy
| | - Roberto Meniconi
- Department of General Surgeon and Transplantations, San Camillo-Forlanini Hospital, Rome, Italy
| | - Andrea Mazzari
- Mini Invasive and General Surgery, Cristo Re Hospital, Rome, Italy
| | - Fabio Barra
- Academic Unit of Obstetrics and Gynaecology, IRCCS Ospedale Policlinico San Martino, Genova, Italy.,Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DiNOGMI), University of Genova, Genova, Italy
| | - Elena Orsenigo
- Department of General and Emergency Surgery, San Raffaele Scientific Institute, Milano, Italy
| | - Davide Pertile
- Department of General Surgery, University of Genoa, Genova, Italy
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Khan U, Kitar M, Krichen I, Maazoun K, Ali Althobaiti R, Khalif M, Adwani M. To determine validity of ultrasound in predicting acute appendicitis among children keeping histopathology as gold standard. Ann Med Surg (Lond) 2018; 38:22-27. [PMID: 30591836 PMCID: PMC6305696 DOI: 10.1016/j.amsu.2018.11.019] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Revised: 11/14/2018] [Accepted: 11/30/2018] [Indexed: 12/04/2022] Open
Abstract
Background To determined the accuracy of ultrasound in diagnosis of acute appendicitis in children keeping histopathology as gold standard. Methods A prospective evaluations of all ultrasound for appendicitis from January 1, 2014, to June 15, 2017, was conducted at our hospital. A diagnostic protocol was implemented to reduce radiation exposure employing US as the initial imaging modality followed by CT for non-diagnostic US studies in patients with an equivocal clinical presentation. The imaging, operative findings, and pathology of 223 patients (females 80, males 143, age less than 14years) with diagnosed appendicitis were collected. The sensitivity, specificity, predictive value, and negative appendectomy rate were also analyzed. All those patients which had subjected to surgery were included to evaluate the true result of ultrasound in diagnosis of appendicitis. Results Of the 223 pediatric appendectomies performed in this time period, a total of 192 (86%) were diagnosed by ultrasound. The histopathology of 8 was normal (3.6%), CT done in 11 and three was normal. The negative appendectomy rate was 3.6%. US were the sole imaging modality in all patients. Conclusions In the diagnosis of acute appendicitis in children, ultrasound is useful and accurate mode, which results in a significant decrease in negative appendectomies with no increase in the number of CT scans. This has important implications in the reduction of childhood radiation exposure. Study design cross sectional validation. Total 223 Diagnose as acute appendicitis on initial clinical basis and follow by ultrasound study. All went for surgery, 8 patient negative by histopathology. Diagnosis by ultrasound 192 out of 223, Sensitivity 86%. Accuracy reaches 92% with secondary signs on ultrasound finding.
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Affiliation(s)
- Ubaidullah Khan
- Pediatric Surgery, Department of Surgery, Alhada Armed Forces Hospital, Taif, Saudi Arabia
| | - Murad Kitar
- Pediatric Surgery, Department of Surgery, Alhada Armed Forces Hospital, Taif, Saudi Arabia
| | - Imed Krichen
- Pediatric Surgery, Department of Surgery, Alhada Armed Forces Hospital, Taif, Saudi Arabia
| | - Kais Maazoun
- Pediatric Surgery, Department of Surgery, Alhada Armed Forces Hospital, Taif, Saudi Arabia
| | - Rasha Ali Althobaiti
- Pediatric Surgery, Department of Surgery, Alhada Armed Forces Hospital, Taif, Saudi Arabia
| | - Mostafa Khalif
- Pediatric Surgery, Department of Surgery, Alhada Armed Forces Hospital, Taif, Saudi Arabia
| | - Mohammad Adwani
- Pediatric Surgery, Department of Surgery, Alhada Armed Forces Hospital, Taif, Saudi Arabia
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Oikonomopoulou N, Míguez-Navarro C, Rivas-García A, García Gamiz M, López-López R, Oliver-Sáez P, Riaño-Méndez B, Farfan-Orte T, Lobato-Salinas Z, Rúbies-Olives J, Llena-Isla P, Lancho-Monreal EM. Assessment of proadrenomedullin as diagnostic or prognostic biomarker of acute appendicitis in children with acute abdominal pain. Am J Emerg Med 2018; 37:1289-1294. [PMID: 30287129 DOI: 10.1016/j.ajem.2018.09.038] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2018] [Revised: 09/25/2018] [Accepted: 09/25/2018] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Acute appendicitis (AA) is one of the most frequent surgical pathologies in pediatrics. OBJECTIVES To investigate the utility of proadrenomedullin (pro-ADM) for the diagnosis of AA. METHODS Prospective, analytical, observational, and multicenter study conducted in 6 pediatric emergency departments. Children up to 18 years of age with suspected AA were included. Clinical, epidemiological, and analytical data were collected. RESULTS We studied 285 children with an average age of 9.5 years (95% confidence interval [CI], 9.1-9.9). AA was diagnosed in 103 children (36.1%), with complications in 10 of them (9.7%). The mean concentration of pro-ADM (nmol/L) was higher in children with AA (0.51 nmol/L, SD 0.16) than in children with acute abdominal pain (AAP) of another etiology (0.44 nmol/L, SD 0.14; p < 0.001). This difference was greater in complicated cases compared with uncomplicated AA (0.64 nmol/L, SD 0.17 and 0.50 nmol/L, SD 0.15, respectively; p = 0.005). The areas under the receiver-operating characteristic curves were 0.66 (95% CI, 0.59-0.72) for pro-ADM, 0.70 (95% CI, 0.63-0.76) for C-reactive protein (CRP), 0.84 (95% CI, 0.79-0.89) for neutrophils, and 0.84 (95% CI, 0.79-0.89) for total leukocytes. The most reliable combination to rule out AA was CRP ≤1.25 mg/dL and pro-ADM ≤0.35 nmol/L with a sensitivity of 96% and a negative predictive value of 93%. CONCLUSION Children with AA presented higher pro-ADM values than children with AAP of other etiologies, especially in cases of complicated AA. The combination of low values of pro-ADM and CRP can help to select children with low risk of AA.
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Affiliation(s)
- Niki Oikonomopoulou
- Pediatric Emergency Department, General and University Hospital Gregorio Marañón, Calle de O'Donnell, 48, 28009 Madrid, Spain.
| | - Concepción Míguez-Navarro
- Pediatric Emergency Department, General and University Hospital Gregorio Marañón, Calle de O'Donnell, 48, 28009 Madrid, Spain
| | - Arístides Rivas-García
- Pediatric Emergency Department, General and University Hospital Gregorio Marañón, Calle de O'Donnell, 48, 28009 Madrid, Spain
| | - Mercedes García Gamiz
- Pediatric Emergency Department, General and University Hospital Gregorio Marañón, Calle de O'Donnell, 48, 28009 Madrid, Spain.
| | - Rosario López-López
- Pediatric Emergency Department, General and University Hospital La Paz, Paseo de la Castellana, 261, 28046 Madrid, Spain
| | - Paloma Oliver-Sáez
- Clinical Analysis Service, General and University Hospital La Paz, Paseo de la Castellana, 261, 28046 Madrid, Spain.
| | - Bibiana Riaño-Méndez
- Pediatric Emergency Department, General and University Hospital San Pedro, Calle Piqueras, 98, 26006 Logroño, La Rioja, Spain.
| | - Tamara Farfan-Orte
- Pediatric Emergency Department, General and University Hospital San Pedro, Calle Piqueras, 98, 26006 Logroño, La Rioja, Spain.
| | - Zulema Lobato-Salinas
- Pediatric Emergency Department, Althaia, Xarxa Assistencia Universitaria de Manresa, C/ Dr. Joan Soler, 1-3, 08243 Manresa, Barcelona, Spain
| | - Júlia Rúbies-Olives
- Pediatric Emergency Department, General and University Hospital Arnau de Vilanova, Avenida Rovira Roure 80, 25198, Lleida, Spain. IRBLleida-Institut de Recerca Biomédica
| | - Priscila Llena-Isla
- Pediatric Emergency Department, General and University Hospital Arnau de Vilanova, Avenida Rovira Roure 80, 25198, Lleida, Spain. IRBLleida-Institut de Recerca Biomédica
| | - Encarnación María Lancho-Monreal
- Pediatric Emergency Department, General and University Hospital of Tajo, Avenida Amazonas Central, s/n, 28300 Aranjuez, Madrid, Spain
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18
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Dokumcu Z, Toker Kurtmen B, Divarci E, Tamay PB, Kose T, Sezak M, Ozok G, Ergun O, Celik A. Retrospective Multivariate Analysis of Data from Children with Suspected Appendicitis: A New Tool for Diagnosis. Emerg Med Int 2018; 2018:4810730. [PMID: 30275991 PMCID: PMC6157147 DOI: 10.1155/2018/4810730] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Revised: 07/17/2018] [Accepted: 08/12/2018] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Decision-making for management may sometimes be difficult in acute appendicitis (AA). Various diagnostic scoring systems exist, but their sensitivity and specificity rates are far from ideal. In this study, the determination of the predictors and the effect of radiological data and developing a new scoring system were aimed. METHODS Medical records of patients who were hospitalized for AA between February 2012 and October 2016 were retrospectively reviewed. All data were compared between patients with and without appendicitis. The multivariate analysis was performed to define significant variables and to examine the sensitivity and specificity of each group of predictors including radiological data. A new scoring system (NSS) was formed and was compared with two existing scoring systems: pediatric appendicitis score (PAS) and Alvarado scoring system (ASS) by using reclassification method. RESULTS Negative appendectomy rate was 11.3%. Statistical analysis identified 21 independently significant variables. The heel drop test had the highest odds ratio. Sensitivity and specificity rates of clinical predictors were 84.6% and 94.8%, respectively. Radiological predictors increased the sensitivity rate to 86.9%. Sensitivity and specificity rates for PAS, ASS, and NSS were 86.8% and 83.9%, 84.7% and 81.6%, and 96.8% and 95.6%, respectively. The "re-assessed negative appendectomy rate" was 6.2% and false positive results were remarkably more common in patients with duration of symptoms less than 24 hours. CONCLUSION Radiological data improves the accuracy of diagnosis. Containing detailed clinical and radiological data, NSS performs superiorly to PAS and ASS, regarding sensitivity and specificity without any age limitation. The efficiency of NSS may be enhanced by determining different predictors for different phases of the inflammatory process.
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Affiliation(s)
- Zafer Dokumcu
- Ege University Faculty of Medicine Department of Pediatric Surgery, Izmir, Turkey
| | - Bade Toker Kurtmen
- Ege University Faculty of Medicine Department of Pediatric Surgery, Izmir, Turkey
| | - Emre Divarci
- Ege University Faculty of Medicine Department of Pediatric Surgery, Izmir, Turkey
| | - Petek Bayindir Tamay
- Ege University Faculty of Medicine Department of Radiology, Division of Pediatric Radiology, Izmir, Turkey
| | - Timur Kose
- Ege University Faculty of Medicine Department of Biostatistics and Medical Informatics, Izmir, Turkey
| | - Murat Sezak
- Ege University Faculty of Medicine Department of Pathology, Izmir, Turkey
| | - Geylani Ozok
- Ege University Faculty of Medicine Department of Pediatric Surgery, Izmir, Turkey
| | - Orkan Ergun
- Ege University Faculty of Medicine Department of Pediatric Surgery, Izmir, Turkey
| | - Ahmet Celik
- Ege University Faculty of Medicine Department of Pediatric Surgery, Izmir, Turkey
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Song CW, Kang JW, Kim JY. Different Clinical Features and Lower Scores in Clinical Scoring Systems for Appendicitis in Preschool Children: Comparison with School Age Onset. Pediatr Gastroenterol Hepatol Nutr 2018; 21:51-58. [PMID: 29383305 PMCID: PMC5788951 DOI: 10.5223/pghn.2018.21.1.51] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Revised: 10/20/2017] [Accepted: 10/23/2017] [Indexed: 01/07/2023] Open
Abstract
PURPOSE To clarify the clinical features of appendicitis in preschool children and to explore clinical appendicitis scoring systems in this age group. METHODS We retrospectively collected data on 142 children, aged 10 years or younger, with confirmed diagnosis of appendicitis based on surgical and pathologic findings. Enrolled subjects were divided into two groups: Group 1 (preschool children aged ≤5 years, n=41) and Group 2 (school children aged >5 to ≤10 years, n=101). Data analyzed included clinical presentation, laboratory findings, the pediatric appendicitis score (PAS), and the modified Alvarado score (MAS). RESULTS The most common presenting symptom was abdominal pain in both groups (92.7% vs. 97.0%). Other presenting symptoms were as follows: fever (65.9%), vomiting (68.3%), right lower quadrant (RLQ) localization (24.4%), anorexia (14.6%), and diarrhea (7.3%) in Group 1, and RLQ localization (74.3%), vomiting (71.3%), anorexia (52.5%), fever (47.5%), and diarrhea (11.9%) in Group 2. Perforation and abscess occurred more frequently in Group 1 than in Group 2 (43.9% vs. 12.9%, p<0.001; 34.1% vs. 5.0%, p<0.001; respectively). PAS and MAS were lower in Group 1 than in Group 2 (4.09±1.97 vs. 6.91±1.61, p=0.048; 4.65±1.79 vs. 6.51±1.39, p=0.012; respectively). CONCLUSION In preschool children, appendicitis often presents with atypical features, more rapid progression, and higher incidence of complications. This age group is more likely to have lower PAS and MAS than those of school children.
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Affiliation(s)
- Chun Woo Song
- Department of Pediatrics, Chungnam National University Hospital, Chungnam National University School of Medicine, Daejeon, Korea
| | - Joon Won Kang
- Department of Pediatrics, Chungnam National University Hospital, Chungnam National University School of Medicine, Daejeon, Korea
| | - Jae Young Kim
- Department of Pediatrics, Gyeongsang National University Changwon Hospital, Changwon, Korea
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Kaiser M, Schroeckenfuchs M, Castellani C, Warncke G, Till H, Singer G. The diagnostic value of hepcidin to predict the presence and severity of appendicitis in children. J Surg Res 2017; 222:102-107. [PMID: 29273360 DOI: 10.1016/j.jss.2017.10.021] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Revised: 09/26/2017] [Accepted: 10/12/2017] [Indexed: 11/30/2022]
Abstract
BACKGROUND The aim of this study was to determine the diagnostic capacity of hepcidin in pediatric acute appendicitis and its accuracy as a predictor of the severity of appendicitis. MATERIALS AND METHODS In children with appendicitis (n = 39), leukocytes, platelet count, and the serum levels of C-reactive protein (CRP) and hepcidin were compared to a control group (n = 25) of patients with unspecific abdominal pain. Additionally, parameters were compared between children with simple (n = 17) and complicated appendicitis (n = 22). Receiver operation characteristic analyses of the different parameters were performed and the areas under the curve (AUCs) calculated. RESULTS Leukocytes and serum hepcidin levels were significantly higher in children with acute appendicitis versus control group (13.7 ± 5.7 versus 9.8 ± 3.9 G/L, P = 0.005 and 31.3 ± 21.7 versus 20.4 ± 14 ng/mL, P = 0.039). AUCs for hepcidin, leukocytes, and CRP were 0.654, 0.711, and 0.619, respectively. Complicated appendicitis was associated with significantly higher hepcidin concentrations compared to simple appendicitis (38.5 ± 17.6 ng/mL versus 21.6 ± 23.4 ng/mL, P < 0.001). A combination of leukocytes, CRP, and hepcidin had the highest AUC (0.914) to predict complicated appendicitis. CONCLUSIONS Increased serum levels of hepcidin were found in children with appendicitis compared to controls. While hepcidin was useful to identify patients with complicated appendicitis as it does not seem appropriate to distinguish between simple appendicitis and other causes for acute abdominal pain.
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Affiliation(s)
- Margarita Kaiser
- Department of Paediatric and Adolescent Surgery, Medical University of Graz, Graz, Austria
| | | | - Christoph Castellani
- Department of Paediatric and Adolescent Surgery, Medical University of Graz, Graz, Austria.
| | - Gert Warncke
- Department of Paediatric and Adolescent Surgery, Medical University of Graz, Graz, Austria
| | - Holger Till
- Department of Paediatric and Adolescent Surgery, Medical University of Graz, Graz, Austria
| | - Georg Singer
- Department of Paediatric and Adolescent Surgery, Medical University of Graz, Graz, Austria
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