An evidence-based clinical protocol for diagnosis of acute appendicitis decreased the use of computed tomography in children

BackgroundCurrently, the routine treatment for acute appendicitis in the United Kingdom is an appendicectomy. However, there is increasing scientific interest and research into non-operative treatment of appendicitis in adults and children. While a number of studies have investigated non-operative treatment of appendicitis in adults, this research cannot be applied to the paediatric population. Ultimately, we aim to perform a UK-based multicentre randomised controlled trial (RCT) to test the clinical and cost effectiveness of non-operative treatment of acute uncomplicated appendicitis in children, as compared with appendicectomy. First, we will undertake a feasibility study to assess the feasibility of performing such a trial.Methods/designThe study involves a feasibility RCT with a nested qualitative research to optimise recruitment as well as a health economic substudy. Children (aged 4–15 years inclusive) diagnosed with acute uncomplicated appendicitis that would normally be treated with an appendicectomy are eligible for the RCT. Exclusion criteria include clinical/radiological suspicion of perforated appendicitis, appendix mass or previous non-operative treatment of appendicitis. Participants will be randomised into one of two arms. Participants in the intervention arm are treated with antibiotics and regular clinical assessment to ensure clinical improvement. Participants in the control arm will receive appendicectomy. Randomisation will be minimised by age, sex, duration of symptoms and centre. Children and families who are approached for the RCT will be invited to participate in the embedded qualitative substudy, which includes recording of recruitment consultants and subsequent interviews with participants and non-participants and their families and recruiters. Analyses of these will inform interventions to optimise recruitment. The main study outcomes include recruitment rate (primary outcome), identification of strategies to optimise recruitment, performance of trial treatment pathways, clinical outcomes and safety of non-operative treatment. We have involved children, young people and parents in study design and delivery.DiscussionIn this study we will explore the feasibility of performing a full efficacy RCT comparing non-operative treatment with appendicectomy in children with acute uncomplicated appendicitis. Factors determining success of the present study include recruitment rate, safety of non-operative treatment and adequate interest in the future RCT. Ultimately this feasibility study will form the foundation of the main RCT and reinforce its design.Trial registrationISRCTN15830435. Registered on 8 February 2017.

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...

Acute Appendicitis in Infants: Still a Diagnostic Dilemma

ObjectiveTo establish the feasibility of a multicentre randomised controlled trial to assess the effectiveness and cost-effectiveness of a non-operative treatment pathway compared with appendicectomy in children with uncomplicated acute appendicitis.DesignFeasibility...

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.

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

Objectives: This study is an evaluation of the accuracy of ultrasonography (USG), computed tomography (CT), and Alvarado score (AS) in the diagnosis and management of acute appendicitis in children. Methods: Records of pediatric patients admitted to the pediatric emergency department (ED) between 2008 and 2012 were evaluated retrospectively. Patient data from the national electronic health information system was screened and those with complete clinical and imaging findings (AS, preoperative USG and/or CT images) and postoperative pathological diagnosis were included in the study. Results: Study group consisted of 449 children with diagnosis of suspected acute appendicitis aged between 3 and 15 years (mean age: 9.20 ± 2.73 years). Of the total, 428 (95.3%) patients underwent appendectomy and 21 (4.7%) cases were treated conservatively. Mean duration of symptoms was 4.94 ± 1.84 hours. Pathological evaluation results were negative (i.e., removal of normal appendix) in 36 (8.4%) patients; histopathological diagnosis was acute appendicitis in 392 (91.6%) patients. Perforated appendix was found in 38 (8.5%) patients. In patients with histopathologically confirmed appendicitis, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of CT in diagnosis of acute appendicitis were 96.3%, 55.6%, 92.8%, and 71.4%, respectively. Sensitivity, specificity, PPV, and NPV of USG were 73.5%, 22.2%, 91.1%, and 69.2%, respectively. Negative appendectomy rate was 6.4% (n = 8) in patients who had preoperative CT scan, and 6.5% (n = 28) in patients who had USG examination. Conclusions: CT has higher sensitivity than USG in diagnosis of acute appendicitis. USG, on the other hand, is widely accessible method and does not use ionizing radiation. Therefore, it may be used as initial radiological imaging method in acute appendicitis. Thin-filter, contrast-unenhanced CT scans may be preferred in cases where clinical signs and USG findings are unclear or controversial.

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.

Background: Acute appendicitis is the commonest cause of emergency abdominal surgeries in children and must be distinguished from other cases of acute abdominal pain. Acute appendicitis not easily diagnosed especially in early stages of the disease. Failure of early diagnosis can lead to progression of the disease with its morbidity and occasional mortality. Ultrasound (US) and The Alvarado score as trials to reduce the negative appendectomy rate without increasing morbidity and mortality. Both have been proven to be a helpful imaging modality and scoring system respectively, in the diagnosis of acute appendicitis in children. Objective: Our study aims to evaluate a combination of clinical scoring (Alvarado score) system and ultrasound findings for accurate diagnosis of acute appendicitis in children. Patient & Method: The study was created in the Babylon Maternity and Pediatric Teaching Hospitals from January 2005 to January 2013. 260 children with right iliac fossa abdominal pain clinically suspected of having acute appendicitis were included in this study and clinically assessed to calculate the Alvarado score. Patients were referred to the radiology department for urgent abdominal US. Results: In present study, 260 patients involved and 114 of them were diagnosed pre-operatively and operated on as acute appendicitis. Of the118patients how were operated, 104 patients proved to have acute appendicitis intraoperatively. The percentage of appendicitis was 88.1% (104/118) and 10 (8.4%) patients had normal appendix. Ovarian cysts pathology was diagnosed in3 girls and another male with omental torsion. The prevalence of appendicitis among the patients of the study was 40% (104/260). Sensitivity of the ultrasound for clinical diagnosis of acute appendicitis was 98.0%, specificity, 96.1%, while that for Alvarado scores 93.0 % and 94.9% respectively. Conclusion: A combination of Alvarado score and abdominal US findings is a good approach for the diagnosis of appendicitis in children to reduce the negative appendectomy rate without increasing morbidity and mortality. In the case of normal appendix or non-visualization of the appendix via abdominal US with a low Alvarado score, appendicitis can be safely excluded. If an inflamed appendix assured on US or a high Alvarado score, patient should be subjected for appendectomy without delay. Patients with low Alvarado scores and positive US findings or moderate and high Alvarado scores with negative US findings should be observed for 24 h and appendectomy is only done when manifestations persist.

Considerable variability exists in the surgical approach to acute appendicitis in children, affecting both quality and costs of care. A national survey provides insight into daily surgical practice and enables comparison of practice with the available evidence. A national survey was conducted in all 121 Dutch hospitals asking detailed information concerning diagnosis and treatment of children suspected of acute appendicitis. An evidence-based practice (EBP) score was developed on the basis of a critical appraisal of the literature, allowing for classification of reported practices with regard to the level of evidence and identification of hospitals working in accordance with the best available evidence. The overall response rate was 93%. For the diagnosis of acute appendicitis, respondents relied predominantly on patient history (29%) and clinical examination (31%), followed by laboratory results (22%). Only 20% of the departments routinely measured total white blood cell count (WBC), C-reactive protein (CRP) and leukocyte differential count (proportion of polymorphonuclear cells), being part of the triad that provides diagnostic evidence. Although strong evidence exists in favour of routine prophylaxis for suspected appendicitis, only two thirds of surgical departments reported this as part of their routine practice. For a number of issues, reasonably consistent evidence is available (e.g. primarily versus delayed closure, drainage versus lavage, routine peritoneal culturing). Thirty-eight percent of the departments routinely cultured abdominal fluid despite various reports that it provides no therapeutic advantage. Not more than 22% of the departments closed the skin in perforated appendicitis in spite of clear supportive evidence. Considerable variation exists in cleaning the abdomen in perforated appendicitis, despite evidence favouring lavage. Comparing departments in terms of compliance with available evidence revealed that most paediatric surgery departments worked according to evidence-based medicine. Available evidence on diagnosis and treatment of acute appendicitis in children is only partly applied in a small proportion of hospitals in the Netherlands. It is recommended that national guidelines be published, which could decrease health care costs and increase more uniform policy, improve quality of care for this group of patients and improve training of residents in general surgery in the Netherlands.

Objective. To assess the predictive value of procalcitonin in detecting acute appendicitis (AP) in children, and to determine a cutoff value of procalcitonin which can safely include/exclude the diagnosis of acute appendicitis in children with acute abdominal pain. Methods. Prospective cohort study of children aged 5–17 years presenting to the emergency room with right lower quadrant (RLQ) tenderness and strong suspicion for acute AP. In addition to standard diagnostic workup for acute AP, a quantitative procalcitonin level was measured using immunoluminometric assay. Recursive partitioning model was used to assess the usefulness of procalcitonin in the diagnosis of appendicitis. Results. Of the 50 children studied, 48% were diagnosed to have AP. The mean procalcitonin level was higher among the children with appendicitis (P = 0.3). Using the recursive partitioning model, we identified a cutoff value of procalcitonin level of 0.39 with a likelihood ratio presence of appendicitis 3.25 and absence of appendicitis 0.8. None of the study subjects with procalcitonin level <0.39 and WBC count of <6.76 K had appendicitis. Conclusions. In conjunction with the clinical symptoms, a procalcitonin level and WBC count could be a strong predictor of acute appendicitis in children.

The aim of this study was to evaluate the feasibility and safety of nonoperative treatment of acute nonperforated appendicitis with antibiotics in children. A pilot randomized controlled trial was performed comparing nonoperative treatment with antibiotics versus surgery for acute appendicitis in children. Patients with imaging-confirmed acute nonperforated appendicitis who would normally have had emergency appendectomy were randomized either to treatment with antibiotics or to surgery. Follow-up was for 1 year. Fifty patients were enrolled; 26 were randomized to surgery and 24 to nonoperative treatment with antibiotics. All children in the surgery group had histopathologically confirmed acute appendicitis, and there were no significant complications in this group. Two of 24 patients in the nonoperative treatment group had appendectomy within the time of primary antibiotic treatment and 1 patient after 9 months for recurrent acute appendicitis. Another 6 patients have had an appendectomy due to recurrent abdominal pain (n = 5) or parental wish (n = 1) during the follow-up period; none of these 6 patients had evidence of appendicitis on histopathological examination. Twenty-two of 24 patients (92%) treated with antibiotics had initial resolution of symptoms. Of these 22, only 1 patient (5%) had recurrence of acute appendicitis during follow-up. Overall, 62% of patients have not had an appendectomy during the follow-up period. This pilot trial suggests that nonoperative treatment of acute appendicitis in children is feasible and safe and that further investigation of nonoperative treatment is warranted.

Improving the Role of CT in Diagnosing Perforated Appendicitis: Can Appendiceal Air Help?

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.

Acute appendicitis is the most common abdominal emergency, but the diagnosis of appendicitis remains a challenge. Endoscopic retrograde appendicitis therapy (ERAT) is a new and minimally invasive procedure for the diagnosis and treatment of acute appendicitis. To investigate the diagnostic value of ERAT for acute appendicitis by the combination of colonoscopy and endoscopic retrograde appendicography (ERA). Twenty-one patients with the diagnosis of suspected uncomplicated acute appendicitis who underwent ERAT between November 2014 and January 2015 were included in this study. The main outcomes, imaging findings of acute appendicitis including colonoscopic direct-vision imaging and fluoroscopic ERA imaging, were retrospectively reviewed. Secondary outcomes included mean operative time, mean hospital stay, rate of complication, rate of appendectomy during follow-up period, and other clinical data. The diagnosis of acute appendicitis was established in 20 patients by positive ERA (5 patients) or colonoscopy (1 patient) alone or both (14 patients). The main colonoscopic imaging findings included mucosal inflammation (15/20, 75%), appendicoliths (14/20, 70%), and maturation (5/20, 25%). The key points of ERA for diagnosing acute appendicitis included radiographic changes of appendix (17/20, 85%), intraluminal appendicoliths (14/20, 70%), and perforation (1/20, 5%). Mean operative time of ERAT was 49.7min, and mean hospital stay was 3.3days. No patient converted to emergency appendectomy. Perforation occurred in one patient after appendicoliths removal was not severe and did not require invasive procedures. During at least 1-year follow-up period, only one patient underwent laparoscopic appendectomy. ERAT is a valuable procedure of choice providing a precise yield of diagnostic information for patients with suspected acute appendicitis by combination of colonoscopy and ERA.