Acute Appendicitis in Infants: Still a Diagnostic Dilemma

Acute appendicitis in infancy

Suspected appendicitis in children: in search of the single best diagnostic test.

Surgery| April 01 2005 Report of a Clinical Practice Guideline for Appendicitis AAP Grand Rounds (2005) 13 (4): 43–44. https://doi.org/10.1542/gr.13-4-43 Views Icon Views Article contents Figures & tables Video Audio Supplementary Data Peer Review Share Icon Share Twitter LinkedIn Tools Icon Tools Get Permissions Cite Icon Cite Search Site Citation Report of a Clinical Practice Guideline for Appendicitis. AAP Grand Rounds April 2005; 13 (4): 43–44. https://doi.org/10.1542/gr.13-4-43 Download citation file: Ris (Zotero) Reference Manager EasyBib Bookends Mendeley Papers EndNote RefWorks BibTex toolbar search nav search search input Search input auto suggest search filter All PublicationsAll JournalsAAP Grand RoundsPediatricsHospital PediatricsPediatrics In ReviewNeoReviewsAAP NewsAll AAP Sites Search Advanced Search Topics: appendicitis, clinical practice guideline Source: Smink DS, Finkelstein JA, Garcia Peña BM, et al. Diagnosis of acute appendicitis in children using a clinical practice guideline. J Pediatr Surg. 2004;39:458–463. A multidisciplinary team of surgeons, emergency medicine physicians, radiologists, and nurses at Children’s Hospital Boston developed a clinical practice guideline (CPG) for the diagnosis and management of acute appendicitis. Appendicitis demands prompt attention and treatment because of its natural progression to perforation. Lacking the perfect diagnostic test, many clinicians have turned their attention to detailed radiologic testing, ranging from ultrasound to computerized tomography (CT) scanning. The authors performed a retrospective cohort study at the Children’s Hospital Boston to evaluate their CPG for acute appendicitis for diagnostic accuracy in children 4 years and older. Patients managed using the CPG during 2001 were compared to children evaluated for acute appendicitis at their institution during 1997 (a period prior to most of the clinical trials using newer radiographic techniques for the diagnosis of appendicitis). Emergency department (ED) staff initially evaluated children and, if acute appendicitis was considered in the differential diagnosis, a surgical consult was obtained prior to ordering radiological studies. Surgical evaluations were performed by PGY 4 or higher surgery residents with supervision of the pediatric surgery attending. Approximately 10% of patients had classic history and physical findings of acute appendicitis and were operated upon acutely. The remaining 90% of patients were further evaluated by CT scan (with rectal and intravenous contrast) or ultrasound. The results of these studies determined whether the patient was managed with surgical or nonsurgical treatment. Those children without evidence of appendicitis on clinical or radiological examinations were discharged from the ED. The study group in 2001 included 571 patients with a mean age of 11.8 years (range 4–21) compared with a total of 388 from the control group in 1997 (mean age 11.4, range 4–22). There were 272 appendectomies in the 2001 group (48%) of which 15 (5.5%) were negative, and 255 appendectomies in the 1997 group (66%) of which 27 (10.6%) were negative (P=.03). Perforation rates were similar in the 2 groups of patients (22.2% among those managed with the CPG vs 28.5% in those in the 1997 group, P=.11). However, admissions for observation decreased dramatically from 143 (37%) in the 1997 group to 34 (6%) in the 2001 group (P<.001). The sensitivity and specificity of the CPG were measured at 98.8% (95% CI, 97.5–100%) and 95.2% (92.9–97.6%), respectively. The authors conclude that a multidisciplinary written CPG was useful in reducing negative appendectomies and admissions for serial examination. Dr. Cavett has disclosed no financial relationships relevant to this commentary. Acute appendicitis remains the most common surgical emergency in childhood, and any help in its early and accurate diagnosis would be of great benefit. An important component to this CPG is the use of focused appendiceal CT with colon contrast (FACT-CC). Recent articles state the radiation exposure from an abdominal CT can be the equivalent of 100–250 chest x-rays and that children... You do not currently have access to this content.

Abdominal Pain in Infants and Children

The clinical presentation of acute appendicitis in infants and young children is nonspecific. The diagnosis is often delayed and is accompanied by high rates of appendiceal perforation. The aim of the present study was to develop an early diagnostic scale for acute appendicitis in children less than 4 years of age. Results: The scale had a high discrimination index area under the ROC curve of 0.96 (95%CI 0.88-0.99), sensitivity of 95.1% (95%CI 86.3-99.0%), specificity of 90.0% (95%CI 55.7-89.5%), positive predictive value of 98.3% (95%CI 90.0-99.7%) and negative predictive value of 75.0% (95%CI 49.4-90.2). Conclusions: In this study, a risk score based on characteristics of children less than 4 years with abdominal pain was developed that may help predict a patient’s risk of developing acute appendicitis. 100 children less than 4 years of age with a presumptive diagnosis of acute appendicitis were retrospectively evaluated in 4 hospitals. The case group comprised 90 patients with histopathological diagnosis of positive appendicitis (with inflammation in the appendiceal wall) while the control group comprised 10 patients with a histopathological diagnosis of negative appendicitis (without inflammation). Epidemiological, clinical, laboratory, and ultrasound variables were screened using Least Absolute Shrinkage and Selection Operator (LASSO) and logistic regression to construct a predictive risk score. Accuracy of the score was measured by the area under the receiver operating characteristic curve. Final model comprised 4 variables (Blumberg's sign, C-reactive protein, neutrophil-lymphocyte index and positive ultrasound). The scale had a high discrimination index area under the ROC curve of 0.96 (95%CI 0.88-0.99), sensitivity of 95.1% (95%CI 86.3-99.0%), specificity of 90.0% (95%CI 55.7-89.5%), positive predictive value of 98.3% (95%CI 90.0-99.7%) and negative predictive value of 75.0% (95%CI 49.4-90.2). In this study, a risk score based on characteristics of children less than 4 years with abdominal pain was developed that may help predict a patient’s risk of developing acute appendicitis.

Background/Aim. Acute appendicitis (AA) is the most frequent emergency and appendectomy is the most frequent abdominal operation in the pediatric surgery. Diagnosis of AA in children is more difficult due to a lack of cooperation and poor clinical history data, leading to significant number of misdiagnostic cases. Our aim was to explore whether neutrophil to lymphocyte ratio (NLR) may be useful in diagnosis and follow-up of AA in children. Methods. Prospective investigation of NLR values in 129 consecutive patients admitted to the Mother and Child Healthcare Institute of Serbia and referred for surgery due to AA was performed. According to the pathohistological findings, patients were divided into 3 groups: normal/early, uncomplicated (phlegmonous) and complicated (gangrenous or/and perforated) AA. Laboratory analysis was done preoperativly and on the 1st and the 3rd postoperative days. Results. Statistically significant differences of NLR values were found in the different time points in total of patients and per groups. Some statistically significant differences of NLR values among histopathological groups were recorded. Investigations of correlation of NLR and other laboratory and clinical parameters showed strong positive correlation between NLR and C-reactive protein postoperatively and between NLR and Pediatric Appendicitis Score (PAS) preoperatively. Strong negative correlation with preoperative symptoms duration (PSD) were also present. Optimal cutoff NLR value between negative and positive appendectomies was 6.14. Conclusion. NLR provides well monitoring of progression of AA in children and, its cutoff values may help in distinguishing the phases of AA. Because of that, NLR should be used in diagnosis of AA in children.

BackgroundAppendectomy is considered the gold standard treatment for acute appendicitis. Recently the need for surgery has been challenged in both adults and children. In children there is growing clinician, patient...

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.

Acute appendicitis is the most common surgical emergency in children. However, it is uncommon in neonates and infants. Often it can be challenging to diagnose acute appendicitis in children due to atypical clinical presentation and nonspecific symptoms. This is particularly true in neonates and infants. A high level of clinical suspicion is needed to diagnose infantile appendicitis. Delayed diagnosis is associated with higher perforation rates and increased disease-related morbidity. Imaging plays a key role in the prompt diagnosis of acute appendicitis and its complications. We report two cases of perforated appendicitis in babies <6 months old.

У літературі широко висвітлюються питання діагностики та лікування гострого апендициту у дітей, однак рання діагностика, особливо у дітей раннього віку, залишається складною проблемою в дитячій хірургії. Мета – аналіз причин незадовільних результатів лікування різних форм гострого апендициту у дітей. Матеріали і методи. Проведений ретроспективний аналіз діагностики та лікування 1034 дітей, які були госпіталізовані у відділення екстреної хірургії ВОДКЛ за період з 2015 р. по 2018 р. з діагнозом гострого апендициту. З них 938 дітей було прооперовано з приводу різних форм гострого апендициту та його ускладнень. З приводу періапендикулярного абсцесу було прооперовано 69 (7,4%) дітей: 42 (61%) хлопчиків і 27 (39%) дівчаток. У віці від 3 до 9 років включно прооперовано 12 (17%) дітей, у віці від 10 до 17 років – 57 (83%) дітей відповідно. У 96 (10,2%) дітей діагноз гострого апендициту був під питанням, а згодом виключена гостра хірургічна патологія. Результати. За останні чотири роки з ускладненими формами гострого апендициту було прооперовано біля 76 дітей, як з приводу періапендикулярного абсцесу, так і з приводу дивертикуліту, апоплексії яєчника, первинного перитоніту, перекруту кісти яєчника. Встановлено, що пізня госпіталізація дітей з діагнозом «гострий апендицит» у лікарняні заклади була пов’язана із соціально-економічними труднощами сільського та міського населення, недооцінкою загальноклінічних симптомів гострого апендициту лікарями первинної ланки та хірургами районних поліклінік і стаціонарів. Усе це призводило до тактики необґрунтованого спостереження та проведення консервативного лікування при невстановленому діагнозі, особливо у дітей ранньої вікової групи. Було складніше проводити диференціальну діагностику гострого апендициту у дітей з атиповим розташуванням апендикулярного відростка. Усі ці чинники призводили до важких ускладнень гострого апендициту у дітей із частим виникненням періапендикулярних абсцесів, що склало майже 30% від усіх прооперованих дітей. Висновки. Висока частота діагностичних помилок на догоспітальному етапі у дітей із підозрою на гострий апендицит зумовлює необхідність покращення знань з питань надання невідкладної допомоги дітям сімейних лікарів, педіатрів та хірургів загальної хірургії. Основним методом ефективного лікування дітей з гострим апендицитом є комплексне лікування в умовах хірургічного стаціонару дитячої лікарні.

Acute appendicitis (AA) is the most common acute surgical condition of the abdomen, and the most commonly misdiagnosed. To analyse the white blood cell count (WBCC) and C-reactive protein (CRP) contribution to the diagnosis of AA in children. This was a retrospective study of 943 consecutive patients operated on with the preoperative diagnosis of AA, in whom preoperative WBCC and CRP had both been measured. Postoperatively, the patients were divided into three groups: normal appendix (no AA), simple AA and complicated AA. Of the 943 patients, 616 (65.3%) had simple AA. The mean (standard deviation (SD)) age for this group was 9.8 (3.2) years (p&lt;0.01 v. complicated AA), the mean WBCC was 16.5 (5.0) × 109/L (p&lt;0.01 v. complicated AA and no AA), and the mean CRP level was 304.8 (409.5) nmol/L (p&lt;0.01 v. complicated AA). The mean age of the patients with complicated AA (283/943, 30.0%) was 7.9 (3.7) years, the mean WBCC was 17.7 (6.2) × 109/L (p&lt;0.01 v. no AA) and the mean CRP level was 1 076.2 (923.8) nmol/L (p&lt;0.01 v. no AA). The mean age of the patients with no AA (44/943, 4.7%) was 8.8 (3.2) years, the mean WBCC was 13.1 (5.3) × 109/L and the mean CRP was 361.9 (447.6) nmol/L. The WBCC was normal in 113/899 patients with appendicitis (12.6%) and CRP in 139 (15.5%). Both the WBCC and CRP were normal in 17patients with appendicitis (1.9%). The best receiver operating characteristic (ROC) curve was obtained for WBCC when comparing all AA with no AA: cut-off point 15.0 × 109/L, sensitivity 65%, specificity 68%, area under the curve 0.70. The best ROC curve for CRP was obtained when comparing simple AA with complicated AA: cut-off point 361.9 nmol/L, sensitivity 74%, specificity 74%, area under the curve 0.81. The WBCC is helpful in diagnosing simple AA and CRP in diagnosing complicated AA. If both are normal, AA is very unlikely. Together the WBCC and CRP are useful tools in diagnosing and staging AA.

Introduction. The typical clinical picture of acute appendicitis (AA) is absent in most of patients, that lead for the high frequency of misdiagnosis with the increase of complicated forms of AA. Due to that, it is necessary to establish the new available laboratory markers, which permitted with the high level of reliability distinguish children not only with AA, but also is appendix perforation. The question what method of appendectomy should be choose – the conventional or mini-invasive – are still under debate. Aim of the study was to summarize the results of diagnosis and treatment of AA in children with the applying of various laboratory markers, ultrasonography (US), and laparoscopy. Materials and methods. This study based on the results of surgical treatment of 3171 children with AA, which were operated during 2009–2018 years. Diagnosis was established on the data of anamnesis, results of objective and laboratory investigation. US was performed in 1183 (37.3%) of patients. Open appendectomy (OA) was performed in 2879 (90.8%) and laparoscopic (LA) – in 292 (9.2%) of patients. With the aim to evaluate the results the methods of variative statistic, determination of specificity, sensitivity, positive (PPV) and negative (NPV) predictive value, etc. were applied. Results. Among the laboratory markers, the best results for the diagnosis of AA showed the neutrophil to lymphocytes ratio (NLR) with the sensitivity – 84.9%, specificity – 67.1%, PPV – 17.8%, and NPV – 98.9%. NLR (sensitivity – 82.5%, specificity – 84%, PPV – 98.5%) and sodium blood level (sensitivity – 90.3%, specificity – 89.9%, PPV – 98.9%) had the best results for the diagnostic of perforated AA. US is the important compound of diagnostic of AA in children with the high level of sensitivity, specificity, PPV, and NPV – 93%, 85%, 86%, and 92%, correspondingly. By the frequency of complications in the early postoperative period, OA and LA had no statistically significant differences, but at follow-up after surgery, LA revealed the sufficient advantages over OA. Conclusions. Among the various laboratory markers, NLR had the better prognostic value for the diagnosis of AA and indices of plasma sodium concentration and NLR for the preoperative diagnosis of perforated appendicitis. US with the high degree of reliability allows to confirm or exclude the diagnosis of AA in children with acute abdominal syndrome. Laparoscopic appendectomy is the real alternative for conventional methods of AA treatment. Besides of the well-known advantages of mini-invasive surgery, the laparoscopic appendectomy had an advantage at the follow-up period. No conflicts of interest was declared by the authors. Key words: acute appendicitis, children, diagnostic, treatment, laparoscopy.

Perforated appendicitis in infancy

Abstract&#x0D; Introduction. Acute appendicitis is the most common case of acute abdomen. Diagnosis of acute appendicitis is still difficult and is one of the problems in the surgical field. The Clinical Scoring System (CSS) has been developed to help doctors classify risk categories. PAS has been widely evaluated in the pediatric population. In another study it was found that RIPASA had better sensitivity, specificity, and accuracy than PAS in pediatric patients.&#x0D; Methods. This study is a cross sectional study to assess the level of concordance between RIPASA and PAS scores in diagnosing acute appendicitis, with the gold standard of Histopathological examination. Samples were taken by consecutive method, in 30 patients aged &lt;18 years for 1 year.&#x0D; Results. This study had an average age of 10.10 ± 3.745 years. Histopathologically early acute appendicitis 3.3%, acute suppurative appendicitis as much as 20%, acute gangrenous appendicitis 73.3% and others 3.3%. Using a cut-off point value of 9.5 for RIPASA and 7 for PAS, the sensitivity, Specificity, Accuracy of 82.75%, 100%, 80% for RIPASA, and 75.8%, 100%, 73.3% for PAS.&#x0D; Conclusion. The RIPASA score on the cut-off treshold 9.5 has better sensitivity and accuracy than PAS in diagnosing acute appendicitis in pediatric patients and can be used as CSS to assist in making decisions regarding the diagnosis of acute appendicitis in children.

An increasing number of studies have indicated that uncomplicated acute appendicitis can be cured with antibiotics alone. Reducing the hazards of appendicitis in infants and young children is a priority problem. It is necessary to search for potential biomarkers for early diagnosis of appendicitis in infants and young children. A retrospective cohort study, including 366 infants and young children treated in the pediatric surgery department, was conducted. Complete blood count, C-reactive protein, and procalcitonin were measured at admission and 24 hours after operation. The median of PCT, CRP, and WBC in the acute appendicitis group and other diseases group were 1.20, 0.11 - 4.06; 16.50, 0.81 - 76.21; 13.51, 7.53 - 26.30 and 0.03, 0.01 - 0.13; 3.35, 0.92 - 6.33; 14.34, 8.84 - 17.23 at the admission, respectively. PCT and CRP were found higher in the acute appendicitis group than that in other abdominal pain diseases group (p < 0.05). WBC is not a specific indicator for identifying acute appendicitis and other abdominal pain diseases (p > 0.05). In different acute appendicitis cases, PCT and CRP significantly increased in complicated appendicitis (p < 0.05). Data showed that WBC mildly increased in complicated appendicitis compared to acute simple appendicitis (p < 0.05). ROC curves showed that PCT was a specific indicator for identifying acute appendicitis and other abdominal pain diseases, AUCPCT = 1.000 (95% CI, 0.999 - 1.000). The median of antibiotic treatment is 4.0 d (95% CI 3.0 - 5.0) in acute appendicitis with PCT results versus 7.0 d (95% CI 5.0 - 9.0) in acute appendicitis without PCT result. PCT shows a high diagnostic ability for appendicitis in infants and young children at admission and assists pediatricians in management of pediatric appendicitis. The combination of these biomarkers is highly recommended. Further studies are needed to confirm our findings.