Diagnostic Accuracy of Abdominal Ultrasonography in Pediatric Acute Appendicitis

Acute Appendicitis in Children: Evaluation of the Diagnostic Efficacy of Ultrasonography and Computed Tomography

OBJECTIVE

Acute appendicitis (AA), the most common cause of acute abdomen in childhood, can result in significant morbidity and mortality if not diagnosed and treated in a timely manner. Diagnosis of AA is more difficult in children due to the limited communication skills, in comparison to adults. The aim of this study is to evaluate the diagnostic accuracy of abdominal ultrasonography (US) and computed tomography (CT) in the diagnosis of AA in children.

MATERIALS AND METHODS

Pediatric patients who were operated on with the diagnosis of AA between January 2016 and December 2021 were retrospectively reviewed. Preoperative abdominal US and CT findings of the patients and postoperative pathology results were recorded.

RESULTS

A total of 263 patients with a mean age of 11.3 years were included in the study. There were 164 (62.3%) males and 99 (37.7%) females. Histopathology revealed AA in 215 (81.7%) patients. Preoperatively, US and CT were performed in 139 (52.8%) and 137 (54.5%), respectively. Both imaging methods were applied to 13 (5.1%) patients. US had a sensitivity and specificity rate of 77.2% and 52.6%, respectively. Positive predictive value (PPV) was found to be 81.2%, whereas negative predictive value (NPV) was 46.5% for US. The diagnostic accuracy rate of US was found as 70.5%. CT had a sensitivity and specificity rate of 88.1% and 57.1%, respectively. PPV was found to be 88.8%, whereas NPV was 55.1% for CT. The diagnostic accuracy rate of CT was found as 81.8%.

CONCLUSION

In case of suspicion of AA, US may be the first choice because it is inexpensive and easily accessible. However, considering patient incompatibility and subjective factors in children, US may sometimes be insufficient. We think that CT should be performed as an advanced examination method in cases where US is not compatible with the patient's condition, not clinic.

The Use of Inflammatory Markers to Rule Out Acute Appendicitis in Pediatrics

Background Acute appendicitis is the most common abdominal surgical emergency in pediatric patients. The diagnosis of acute appendicitis in pediatrics is challenging and requires an accurate physical examination, laboratory study, and imaging. The aim of this study was to determine the benefits of using three inflammatory markers, white blood count (WBC), neutrophils percent (NE%), and C-reactive protein (CRP), in ruling out appendicitis in pediatric patients. Methods A retrospective study was conducted of 152 pediatric patients aged between 6 months and 14 years presenting to the emergency department between January 2018 and December 2020, with the diagnosis of appendicitis as the primary physician's main diagnosis. Demographic information and clinical data were extracted from the medical file for each patient. Results Out of the 152 patients included, 68 (44.7%) were female and 84 (55.3%) were male, with median age was 8.1 years. Thirty-six (23.7%) had acute appendicitis confirmed by histopathology. Of these 36 patients, only two patients (5.6%) had all inflammatory markers within normal limits. Conclusion  Although raised inflammatory markers may help diagnose acute appendicitis, their role in ruling it out remains limited.

Diagnostic performance of calprotectin and APPY-1 test in pediatric acute appendicitis: a systematic review and a meta-analysis

BACKGROUND

Pediatric acute appendicitis (AA) is a challenging pathology to diagnose. In the last decades, multiple biomarkers have been evaluated in different human biological samples to improve diagnostic performance. This study aimed to examine the diagnostic performance of serum, fecal and urinary calprotectin as well as the role of the APPY-1 biomarker panel in pediatric acute appendicitis.

METHODS

We conducted a systematic review of the literature that involved an extensive search in the main databases of medical bibliography (Medline, PubMed, Web of Science and SciELO). Two independent reviewers selected the relevant articles based on the previously defined inclusion and exclusion criteria. Methodological quality of the selected article was rated using the QUADAS2 index. Data extraction was performed by two independent reviewers. A synthesis of the results, a standardization of the metrics and two random-effect meta-analyses, one for serum calprotectin and one for APPY-1, were performed.

RESULTS

The research resulted in 173 articles. Thirty-eight duplicates were removed. Among the remaining 135 articles, we excluded 125 following the inclusion and exclusion criteria, resulting in the 10 studies included in this review. This systematic review included data from of 3901 participants (1276 patients with confirmed diagnosis of AA and 2625 controls). The age of the participants ranged from 0 to 21 years. Four of the studies compared serum calprotectin values and reported significant differences between groups, but inconsistent results regarding cutoff points, sensitivity and specificity. Two publications compared urinary values of calprotectin and presented inconsistent results regarding sensitivity and specificity as well. One publication evaluated the diagnostic performance of fecal calprotectin, but it did not provide data on measured values. Four studies evaluated the diagnostic performance of APPY-1 test in pediatric acute appendicitis. The calculated pooled sensitivity and specificity of those studies were 97.37 (95% CI 95.60-98.44) and 36.74 (95% CI 32.28-41.44), respectively, and the calculated pooled NLR, 0.0714 (95% CI 0.041-0.115).

CONCLUSION

Serum calprotectin has limited diagnostic yield in pediatric acute appendicitis. Its performance seems to increase with the hours of clinical evolution and in advanced AA, although the evidence is limited. There is not enough evidence on the usefulness of urinary or fecal calprotectin in the diagnosis of pediatric acute appendicitis. On the other hand, the APPY-1 is a reliable test to exclude the diagnosis of AA in patients at low or moderate risk according to PAS and Alvarado Score.

Diagnostic accuracy of ultrasound in the paediatric population with acute right iliac fossa pain, our District General Hospital experience

AIM

This project aimed to evaluate the role of ultrasound scan (USS) in children presenting with acute onset right iliac fossa (RIF) pain and suspected appendicitis.

METHODS

We retrospectively studied 100 consecutive children undergoing USS for RIF pain. Children with low to moderate clinical probability of appendicitis were seen by the surgical team and subsequently underwent USS by a radiologist or a sonographer with a special interest in paediatric USS. The clinical findings, blood tests, and radiological diagnosis led to a decision to operate, observe or discharge. USS findings were subsequently verified with the final histology. The six-month follow-up data of these patients were also analysed.

RESULTS

35 males, median age of 11 years (range 4-17), and 65 females, median age of 14 years (range 6-18) were included. A total of 23 appendicectomies were performed. On histology appendicitis was confirmed in 20, including 16 pre-operatively diagnosed on USS. 6 of these appendicectomies were performed on clinical suspicion with normal USS. 1 patient was diagnosed with neuroendocrine tumour of the appendix. Only 2 negative appendicectomies were performed. 62 patients were discharged without intervention. USS sensitivity was 74%, and specificity was 92% for appendicitis. An additional 16 patients were identified with alternate pathology including 5 ovarian cysts.

CONCLUSION

Appendicitis was more common in male patients; however, there was no difference in overall disease prevalence in male or female paediatric patients. Thus, USS is a valuable tool to exclude appendicitis in children with low to moderate probability.

Paediatric Acute Appendicitis: A Comparison of Diagnostic Accuracy of Three Pre-operative Diagnostic Modalities

INTRODUCTION

The diagnosis of acute appendicitis (AA) is usually clear cut but sometimes there is atypical presentation of this condition in children. There is a need to determine and compare the diagnostic accuracy of these three pre-operative diagnostic modalities: Paediatric Appendicitis Score (PAS), abdominal ultrasonographic scan (USS) findings, and serum C-reactive proteins (CRPs). The objective of this study was to determine the diagnostic accuracy of the three diagnostic modalities and to compare each diagnostic test result with the histopathological results of the appendix specimens.

MATERIALS AND METHODS

This was a prospective cross-sectional study that involved children aged 4-15 years with suspected AA who presented at the emergency paediatric unit of a tertiary health care hospital in North Central, Nigeria. The PAS, quantitative serum CRP, and abdominal USS were performed for all eligible patients.

RESULTS

A total of 43 patients were included in this study. Forty appendicectomy specimens (93%) were histologically confirmed to be AA and three appendicectomy specimens (7%) were normal appendix. The diagnostic accuracy values of PAS, abdominal USS, and CRP were 95.3%, 93.0%, and 90.7%, respectively.

CONCLUSION

This study demonstrated that PAS, abdominal USS, and serum CRP provided useful diagnostic accuracy for AA in children.

Abdominal Ultrasound and Its Diagnostic Accuracy in Diagnosing Acute Appendicitis: A Meta-Analysis

Background: Acute appendicitis (AA) is a common cause of abdominal pain encountering unnecessary surgeries in emergency departments. The present meta-analysis aims to assess the accuracy of abdominal ultrasound in suspected acute appendicitis cases in terms of sensitivity, specificity, and post-test odds for positive and negative results.

Materials and Methods: An extensive and systematic search was conducted in Medline (via PubMed), Cinahl (via Ebsco), Scopus, and Web of Sciences from 2010 till the end of March 2021. Two authors analyzed studies for inclusion, collected results, and conducted analyses separately. Examination of the histopathological tissue collected during appendectomy served as a gold standard for determining the final diagnosis of appendicitis. The accuracy was determined by evaluating sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), diagnostic odds ratio.

Results: Out of 3,193 references, a total of 18 studies were selected. Overall sensitivity of 77.2% (95% CI – 75.4–78.9%) and specificity of 60% (95% CI – 58–62%) were observed. The diagnostic odds ratio of 6.88(95% CI 1.99–23.82) was obtained.

Conclusion: Abdominal ultrasound shows significant accuracy of diagnosis in patients with suspected acute appendicitis.

Predictors risk factors for acute complex appendicitis pain in patients: Are there gender differences?

Objective:

The purpose of this study is to determine the predictive risk factors for appendicitis and the cost-effectiveness of using abdominal helical computed tomography (CT) in comparison to abdominal ultrasonography (US) for the diagnosis of acute appendicitis in patients.

Subjects and Methods:

The typical case was a patient with abdominal pain in the right lower quadrant and suspicion of appendicitis. A total of 643 patients who were consequently treated with appendectomy upon diagnosis of acute appendicitis between January 2015 and December 2018 were included in the study. The four diagnostic alternatives chosen were US, CT, biochemistry parameters, and physical examination in the hospital.

Results:

There were statistically significant differences between male and female patients with regards to age, BMI, cigarette smoking, sheesha smoking, family history of diabetes, hypertension and family history of gastrointestinal discomfort (GI), anxiety (P < 0.001), red eye (P = 0.006), dizziness (P = 0.021), headache (P < 0.001), muscular symptoms, weakness and cramps (P < 0.001), bloating or swollen stomach (P < 0.001), UTI (P < 0.001), chest pain (P < 0.001), guarding (P < 0.001), loss of appetite (P = 0.004), nausea (P < 0.001) vomiting (P = 0.042), anorexia (P = 0.009), and constipation (P = 0.002). Moreover, there were statistically significant differences between male and female patients for pain (P < 0.001), pain right belly (P = 0.027), severe crumps (P = 0.007), high temperature and fever (P < 0.001), irritable bowel syndrome (P < 0.001), right iliac fossa (RIF) pain (P = 0.008), rebound tenderness (P = 0.024), positive bowel sounds (P = 0.029), and pointing tenderness (P < 0.001). Multivariate stepwise logistic regression showed nausea (P < 0.001), C-reactive protein (CRP) (P < 0.001), dizziness (P = 0.016), vomiting (P < 0.001), muscular symptoms (P = 0.007), irritable bowel syndrome (P = 0.034), guarding (P = 0.040), and loss appetite (P = 0.046) were considered at higher risk as predictors for appendicitis patients.

Conclusions:

CT is more cost-effective than the US and clinical examination for determining appendicitis. The current study suggested that nausea, C-reactive protein, dizziness, vomiting, muscular symptoms, irritable bowel syndrome, guarding, and loss appetite were considered as higher risk predictors for appendicitis patients.