Inflammatory Markers and Duration of Symptoms Have a Close Connection With Diagnosis and Staging of Acute Appendicitis in Children

The Association Between C-Reactive Protein Levels and Pediatric Appendicitis Score and the Severity of Appendicitis in Children

BACKGROUND

Acute appendicitis is a common cause of abdominal pain leading to emergent abdominal surgery in children. C-reactive protein (CRP), an inflammatory marker typically elevated in acute appendicitis, and Pediatric Appendicitis Score (PAS), a clinical scoring system used for the diagnosis of appendicitis, have the potential to predict the severity of inflammation of the appendix. This may be useful in helping the physician make a treatment plan prior to surgery.

OBJECTIVE

The purpose of this study was to assess whether CRP value and PAS differ with the extent of inflammation of the appendix seen on histologic examination.

METHODS

This was a prospective observational study of patients diagnosed with acute appendicitis via computed tomography or ultrasound. Enrolled patients had CRP levels drawn, PAS calculated, and appendix pathology reviewed. Appendix pathology was categorized by the pathologist on the basis of the level of inflammation: simple, suppurative, gangrenous, and perforated.

RESULTS

One hundred sixty-three patients were enrolled. CRP levels and PAS were statistically different (p < 0.002) among the four pathology classifications. Patients with simple appendicitis (n = 3) had a mean CRP of 2.95 mg/L and PAS of 3.9, patients with suppurative appendicitis (n = 99) had a mean CRP of 26.89 mg/L and PAS of 6.5, patients with gangrenous appendicitis (n = 56) had a mean CRP of 91.11 mg/L and PAS of 7.5, and patients with perforated appendicitis (n = 6) had a mean CRP of 154.17 mg/L and PAS of 7. The results remained statistically significant (p < 0.002) after adjusting for age, race, and sex. When combined-PAS ≥ 8 and CRP level > 40 mg/L-the specificity of complicated appendicitis was 91.2% and positive predictive value was 72.7%.

CONCLUSIONS

Higher CRP levels and PAS were associated with increased histologic inflammation of the appendix. This study provides preliminary evidence that CRP and PAS could potentially assist in treatment decisions for appendicitis.

Artificial intelligence differentiates abdominal Henoch-Schönlein purpura from acute appendicitis in children

OBJECTIVE

This study aims to construct an artificial intelligence (AI) model capable of effectively discriminating between abdominal Henoch-Schönlein purpura (AHSP) and acute appendicitis (AA) in pediatric patients.

METHODS

A total of 6965 participants, comprising 2201 individuals with AHSP and 4764 patients with AA, were enrolled in the study. Additionally, 53 laboratory indicators were taken into consideration. Five distinct artificial intelligence (AI) models were developed employing machine learning algorithms, namely XGBoost, AdaBoost, Gaussian Naïve Bayes (GNB), MLPClassifier (MLP), and support vector machine (SVM). The performance of these prediction models was assessed through receiver operating characteristic (ROC) curve analysis, calibration curve assessment, and decision curve analysis (DCA).

RESULTS

We identified 32 discriminative indicators (p < .05) between AHSP and AA. Five indicators, namely the lymphocyte ratio (LYMPH ratio), eosinophil ratio (EO ratio), eosinophil count (EO count), neutrophil ratio (NEUT ratio), and C-reactive protein (CRP), exhibited strong performance in distinguishing AHSP from AA (AUC ≥ 0.80). Among the various prediction models, the XGBoost model displayed superior performance evidenced by the highest AUC (XGBoost = 0.895, other models < 0.89), accuracy (XGBoost = 0.824, other models < 0.81), and Kappa value (XGBoost = 0.621, other models < 0.60) in the validation set. After optimization, the XGBoost model demonstrated remarkable diagnostic performance for AHSP and AA (AUC > 0.95). Both the calibration curve and decision curve analysis suggested the promising clinical utility and net benefits of the XGBoost model.

CONCLUSION

The AI-based machine learning model exhibits high prediction accuracy and can differentiate AHSP and AA from a data-driven perspective.

IL-6 Serum Levels Can Enhance the Diagnostic Power of Standard Blood Tests for Acute Appendicitis

Background: The diagnosis of acute appendicitis (AA) remains challenging, especially in pediatrics, because early symptoms are not specific, and the younger the patient the more difficult their interpretation is. There is a large degree of agreement between pediatric surgeons on the importance of an early diagnosis to avoid complicated acute appendicitis (CAA) and its consequences. The aim of this study is to assess if Interleukin 6 (IL-6) could enhance the sensitivity (Sn) and specificity (Sp) of the currently available and routinely performed diagnostic tools in case of suspected AA in pediatric patients. Materials and Methods: A prospective observational study was conducted including patients who underwent appendectomy between November 2020 and March 2022. We divided patients into three groups: not inflamed appendix (group NA), not complicated AA (group NCAA), and complicated AA (group CAA). We compared the mean values of white blood cells (WBC), neutrophils, fibrinogen, ferritin, aPTT, INR, C-reactive protein (CRP), IL-6, and CRP between the three groups. Then we evaluated Sn, Sp, and odds ratio (OR) of IL-6 and CRP alone and combined. Results: We enrolled 107 patients operated on for AA (22 in Group NA, 63 in Group NCAA, and 21 in group CAA). CRP levels resulted in a significant increase when comparing CAA with NA (p = 0.01) and CAA with NCAA (p = 0.01), whereas no significance was found between NA and NCAA (p = 0.38). A statistically significant increase in average IL-6 levels was found when comparing NCAA with NA (p = 0.04), CAA with NA (p = 0.04), and CAA with NCAA (p = 0.02). Considering CRP alone, its Sn, Sp, and OR in distinguishing NA from AA (both NCAA and CAA together) are 86%, 35%, and 33,17, respectively. Similarly, Sn, Sp, and OR of IL-6 alone are 82%, 54%, and 56, respectively. Combining CRP and IL-6 serum levels together, the Sn increases drastically to 100% with an Sp of 40% and OR of 77. Conclusions: Our study may suggest an important role of IL-6 in the detection of AA in its early stage, especially when coupled with CRP.

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.