Appendicitis Score Research Articles

774 Paediatric Appendicitis Score (PAS): A Local Trial of a Risk Prediction Pathway

Abstract Aim Right iliac fossa (RIF) pain remains the commonest acute general surgical presentation in children. Our centre had been an outlier compared with the national average in terms of negative appendicectomy rates. Thus, we designed and implemented a local pathway for risk stratification and management of children with RIF pain. Method The first phase was a retrospective analysis of all appendicectomies performed between April 2018 and March 2019, in children aged five to seventeen years old. Pre-operative inflammatory markers, clinical signs, and histology findings were analysed. Second phase involved designing a pathway utilizing Paediatric Appendicitis Score (PAS), a ten-point scoring system when assessing children with RIF pain. The final phase was a prospective analysis of appendicectomy results performed between August and November 2019, after implementing PAS pathway. Results 92 cases were recruited in the first phase (mean age 12.3). 22 cases were analysed in the final phase after implementing PAS pathway (mean age 10.9). Our negative appendicectomy rates had reduced from 25% to 15.4%. In addition, we found that 96% of positive appendicectomies had either raised inflammatory markers (WCC or CRP), raised PAS (Score of ≥ 4), or both. Conclusions There is noticeable difference in our negative appendicectomy rates since the introduction of PAS pathway. A diagnosis of appendicitis in a child with normal inflammatory markers and PAS score seemed unlikely. Our goal is to continue utilizing the PAS pathway in our department in order to reduce unnecessary surgeries in children.

The Determination of Appendicitis from Folate Acid and Vascular Endothelial Growth Factor Level in Animal Model: A Review

BACKGROUND: Appendicitis is one of the most common abdominal emergencies that require surgery in children. The morbidity and mortality rate in appendicitis is greatly affected by rupture or leakage of the appendix. In establishing the diagnosis of appendicitis, several modalities are acknowledged, namely, pediatric appendicitis score and ultrasound. Pathologically, severity and complications of appendicitis occur related to good vascularization and tissue healing process through process of angiogenesis influenced by folic acid (FA) and vascular endothelial growth factor (VEGF). This is clinically important as currently non-operative and non-invasive therapies were developing in stratification of mild appendicitis. AIM: This study aimed to review the determination of appendicitis from FA and VEGF levels in animal model. METHODS: This study was conducted in accordance with the PRISMA guidelines for reporting systematic reviews. Articles were reviewed for relation of FA and VEGF in determining appendicitis in PubMed and Science Direct. Articles on experimental animal model published from 1990 to 2020 were included, while articles in English were excluded from the study. RESULTS: The articles we reviewed conduct an assessment of appendicitis by FA and VEGF level in animal model. Three articles were reviewed ranging from 1990 to 2020. One article presented a significant association of decreased level of FA in determining appendicitis while the other two mentioned trends of decreased level of FA and VEGF in appendicitis without statistically significance. CONCLUSION: Reduction of folate acid levels could be a critical prescient factor for the weight of muddled an appendicitis in animal model, however, there was a pattern demonstrating low estimation of VEGF as an indicator of appendicitis and convoluted appendix with no measurable note worthiness appeared.

The use of a score-based protocol in pediatric appendicitis decreases CT scan utilization when evaluating children in a community hospital

BackgroundThe Pediatric Appendicitis Score (PAS) is a validated scoring system assessing children with abdominal pain. Prior to 2016, children with abdominal pain in our community hospital were evaluated primarily using CT scans. A protocol using PAS and ultrasound (US) as the primary radiologic modality was adopted in 2016 for evaluating children with abdominal pain. The protocol consisted of three tiers with low PAS requiring no radiologic evaluation; moderate PAS requiring US and high PAS requiring initial surgical consultation. Retrospective chart review of children presenting with clinically suspected appendicitis was performed from January 2015 through December 2017, representing 1 year before and 2 years after implementation of PAS protocol. PAS scoring was assigned retrospectively to patients not scored in the emergency physician’s note, and statistical analysis of the patient cohorts was performed using SPSS, version 17. This study was approved by the University of Nevada Institutional Review Board.ResultsApplication of PAS scoring system increased use of US as the primary radiologic test from 59% pre-protocol to 91% post protocol and decreased use of CT scans from 41 to 8% (p < .05). Physician adherence to protocol improved from 59 to 71%, increasing further to 81% in the 2nd year post-protocol (p < .05). The highest rate of non-compliance was noted when providers ordered an US in patients with a low PAS, followed by ordering any radiologic tests in patients with a high PAS.ConclusionImplementation of PAS-based protocol altered clinician behavior in a community hospital when evaluating children with clinically suspected appendicitis. Improved adherence to the protocol over time with significant decrease of CT scans ordered thereby reducing radiation exposure in the pediatric population. Future improvements will be aimed at decreasing radiologic testing in patients with a low PAS and involving surgeons earlier with patients who have a high PAS as clinical acceptance to the protocol matures.

English

BACKGROUND Acute appendicitis is very commonly diagnosed when a patient presents with acute abdomen. This is more commonly seen in the young and middle-aged individuals. The clinical signs and symptoms determine the diagnosis and management. Scoring systems are in plenty to diagnose acute appendicitis and mainly include the presenting signs and symptoms, but are not acceptable for all populations with different age groups. Modified Alvarado scoring system is a timed tested scoring system used in different populations and age groups with good efficacy and to provide a bedside clinical diagnosis of acute appendicitis. The purpose of this study was to assess effectiveness of modified Alvarado score in the early diagnosis of acute appendicitis. METHODS A prospective observational study was done which incorporated 50 patients presenting with the signs and symptoms pointing out to acute appendicitis, clinically. The patients were evaluated by Modified Alvarado score during admission and based on the treating surgeon’s decision, were operated. Finally, the score was compared with the diagnosis achieved with a histopathological examination of the operated specimen. RESULTS The sensitivity of raja isteri penigran anak saleha appendicitis (RIPASA) score was 70.58 %, specificity was 68.75 %, positive predictive value (PPV) was 82.75 %, negative predictive value (NPV) of RIPASA score was 52.38 % and the diagnostic accuracy of RIPASA score was 70 %. CONCLUSIONS Modified Alvarado scoring system is simple scoring system which can be used in a bedside manner but uses specific and limited features for the diagnosis of acute appendicitis which limits the effectiveness of this scoring system. KEY WORDS Acute Abdomen, Clinical Scoring System, Modified Alvarado Scoring System

Antibiotics as first-line alternative to appendicectomy in adult appendicitis: 90-day follow-up from a prospective, multicentre cohort study.

BackgroundUncomplicated acute appendicitis can be managed with non-operative (antibiotic) treatment, but laparoscopic appendicectomy remains the first-line management in the UK. During the COVID-19 pandemic the practice altered, with more patients offered antibiotics as treatment. A large-scale observational study was designed comparing operative and non-operative management of appendicitis. The aim of this study was to evaluate 90-day follow-up.MethodsA prospective, cohort study at 97 sites in the UK and Republic of Ireland included adult patients with a clinical or radiological diagnosis of appendicitis that either had surgery or non-operative management. Propensity score matching was conducted using age, sex, BMI, frailty, co-morbidity, Adult Appendicitis Score and C-reactive protein. Outcomes were 90-day treatment failure in the non-operative group, and in the matched groups 30-day complications, length of hospital stay (LOS) and total healthcare costs associated with each treatment.ResultsA total of 3420 patients were recorded: 1402 (41 per cent) had initial antibiotic management and 2018 (59 per cent) had appendicectomy. At 90-day follow-up, antibiotics were successful in 80 per cent (1116) of cases. After propensity score matching (2444 patients), fewer overall complications (OR 0.36 (95 per cent c.i. 0.26 to 0.50)) and a shorter median LOS (2.5 versus 3 days, P < 0.001) were noted in the antibiotic management group. Accounting for interval appendicectomy rates, the mean total cost was €1034 lower per patient managed without surgery.ConclusionThis study found that antibiotics is an alternative first-line treatment for adult acute appendicitis and can lead to cost reductions.

Comparison of Appendicitis Scoring Systems in Pediatric Patients

BACKGROUND: Acute appendicitis is one of the most common causes of emergency department (ED) admission among pediatric patients, and the most common cause of abdominal pain requiring surgical intervention. The present study aimed to measure the success of three different appendicitis scoring systems in patients who were operated due to acute appendicitis (AA) upon presenting at the pediatric ED with acute abdominal pain. METHODS: The study included a total of 226 patients who were admitted to Pediatric Emergency Department and who underwent an appendectomy between December 2018 and May 2019. Through a retrospective review of patient files; age, gender, clinical findings, laboratory results, Pediatric Appendicitis Score (PAS), Lintula score, Acute Inflammatory Response (AIR) score, ultrasonography (USG) findings and pathology results of the patients operated due to AA were recorded. RESULTS: A total of 226 patients were included in the study, with a mean age of 11.6±3.66 (1-17) years, and 57.1% (n=129) of the patients were female and 42.9% (n=97) were male. The pathology results were evaluated under three categories: suppurative (phlegmonous) appendicitis, 74.3%; perforated appendix, 9.7%; and reactive lymphoid hyperplasia, 15.9%. The cut-off values &amp;gt;3 for AIR, &amp;gt;7 for PAS and &amp;gt;15 for Lintula were found statistically significant. Among the three scoring systems, Lintula had the highest sensitivity (91.5%) and PAS had the highest specificity (69.4%). DISCUSSION:Although scoring systems are used to diagnose AA, the selected cut-off values for the scoring systems have an effect on the results.. Patients with a PAS score of ≥7 were found to have more significant AA results. We believe that PAS is likely to be a preferred scoring system in pediatric patients, especially under busy ED conditions; however, further studies with larger populations are needed to develop scoring systems that will guide physicians to establish a final diagnosis.

Comparison of Alvarado Score and Paediatric Appendicitis Score for Diagnosing Appendicitis in Children

Objective: To compare diagnostic accuracy of Alvarado score (AS) and Paediatric Appendicitis Score (PAS) for diagnosis of acute appendicitis in children. Methods: This study was conducted at the department of Pediatric Surgery Children Hospital Lahore, over a period of 1 year. All the patients undergoing appendicectomy were included. Alvarado score and Pediatric Appendicitis score (PAS) was evaluated, compared and appendix specimen sent for histopa-thology. All findings were recorded in proforma. The collected data was analyzed by SPSS version 24. The mean Alvarado score and PAS was calculated, and stratified according to the histopathology reports. The sensitivity and specificity of both Alvarado score and PAS for three strata including score 3-5, 5-7 and 8-10 were also calculated. Results: A total of 177 patients were included in the study. The mean age of the patients was 9.16 ± 2.386 years. Among these 118 patients (67%) were male. The mean duration of pain was 21.42 ± 19.05 hours. Biopsy report showed that 18 patients (10.1%) had normal appendix with no signs of inflammations while 159 patients (89.9%) had inflammation on histopathology. We stratified the histopathology reports according to Alvarado score ≤7 and &gt;7 and P-value was found significant. Similarly PAS ≤7 and &gt;7 was stratified and P-value was not significant. The difference in mean Alvarado score between having acute appendicitis and those with normal histopathology was significant (P= 0.000) while this difference in mean PAS was not found significant (P= 0.325). Conclusions: None of the scoring system has adequate diagnostic accuracy and clinical judgment is preferred. Key Words: Alvarado Score; PAS; Appendicitis; Children How to cite: Liaqat N., Iqbal A., Rehman ur W., Ahmed Z., Bashir F., Dar H.S. Comparison of Alvarado score and Paediatric Appendicitis Score for diagnosing appendicitis in children” Esculapio 2021;17(02):175-178.

Ultrasound for Appendicitis: Performance and Integration with Clinical and Laboratory Parameters

Objective: We aimed to assess the relationship between white blood cell count, pediatric appendicitis score and the measurement of the outer diameter of the appendix. Methods: The study was performed on 480 children admitted for suspected acute appendicitis and underwent an appendectomy at the National Center for Maternal and Child Health, Ulaanbaatar, Mongolia, between May 2019 and December 2019. Clinical diagnosis was performed using the pediatric appendicitis score based on the pre-operative blood test results, including white blood cell count, neutrophil count, lymphocytes count, and neutrophil-lymphocyte ratio. The diameter of the appendix was determined by ultrasound. Results: 516 pediatric patients (≤ 18 years old) were suspected of having acute appendicitis and subsequently underwent surgery. The pediatric appendicitis score and neutrophil-lymphocyte ratio were moderately correlated (r = 0.494), but the neutrophil-lymphocyte ratio and outer diameter of the appendix were poorly correlated (r = 0.169). In patients with an appendix outer diameter of ≤ 6 mm, 44% were inflamed, and 56% were not. Conclusions: Ultrasonic measurement of the outer diameter of the appendix had a 79.8% accuracy. This diagnostic accuracy can be enhanced with the combined usage of the pediatric appendicitis score and the neutrophil-lymphocyte ratio.

Diagnostic accuracy of Leucine-rich \u03b1-2 glycoprotein (LRG) as a urinary biomarker in pediatric appendicitis: a prospective observational pilot study from Eastern India

BackgroundRecently, several serum and urinary biomarkers have been investigated for diagnosis of acute appendicitis. Urinary biomarkers seem to be advantageous in children as it is non-invasive, painless, and easy to perform. Leucine-rich α-2-glycoprotein (LRG) is regarded as a reliable urinary biomarker for the diagnosis of pediatric appendicitis. A prospective observational pilot study was conducted in children presenting with abdominal pain. Assessment of pediatric appendicitis score (PAS), routine blood tests, and measurements of urinary LRG was done. The present study aimed to evaluate the diagnostic accuracy of urine LRG in appendicitis in Indian children and to assess the concentration of urine LRG at which it will guide the management.ResultsLRG had a receiver operating characteristic (ROC) area under the curve (AUC) of 0.586 (95% CI 0.407–0.766). There was no specific cut-off identified using Youden’s index. ROC analysis of the PAS score resulted in an AUC of 0.821 (95% CI 0.691–0.952). Using Youden’s index, the cut-off for PAS scoring was identified as 6.5 with the sensitivity of 80%, the specificity of 76.2%, positive predictive value 76.19%, negative predictive value as 80%, and diagnostic accuracy of 78%.ConclusionsLRG could not show better diagnostic performance compared to routine blood tests and PAS scores. There was no specific cut-off value at which it will differentiate mesenteric adenitis and acute appendicitis and guide their management. With 78% diagnostic accuracy, PAS score (> 6) is still a better tool for the diagnosis of acute appendicitis.Trial registrationClinical Trials Registry Government of India, CTRI/2018/01/011182, Registered on: 08 Jan 2018.

English

BACKGROUND Accurate clinical diagnosis and timely surgical intervention are the two important events that help the surgeon in the management of acute appendicitis. Two diagnostic score systems that help in avoiding the removal of normal appendix are reviewed in this study. The purpose of this study was to evaluate the sensitivity and specificity of Alvarado score (AS) and Appendicitis inflammatory response scores (AIRS) in the diagnosis of acute appendicitis (AA) and correlate their efficacy in the management of acute appendicitis as per the diagnostic scores used. METHODS This was a cross-sectional clinical study. 73 patients who attended the emergency ward for clinical features of acute appendicitis were included in the study. Clinical examination included the diagnostic tools 1. The Alvarado score, 2. Appendicitis Inflammatory Response score. Based on their score a provisional diagnosis was made among the patients. All the data was classified and analysed. RESULTS The positive predictive value was 63/73 (86.30 %) with Alvarado diagnostic tool and 66/73 (90.41 %) with AIS diagnostic tool. The false positive values using Alvarado system was 06.84 % and 04.10 % with AIS system. The true negative rate of diagnosis of acute appendicitis in this study was 09.58 %. CONCLUSIONS Both Alvarado and AIS diagnostic tools were simple and accurate in the early diagnosis of acute appendicitis in the adult population. Both the tools are highly sensitive and specific in nature. KEYWORDS Appendix, Acute Appendicitis, Perforation, USG, Laparotomy and Alvarado Score

Comparison of Alvarado score and pediatric appendicitis score for clinical diagnosis of acute appendicitis in children\u2014a prospective study

BackgroundAcute appendicitis is the most common surgical condition of children. Differential diagnosis of an acutely inflamed appendix in children includes a vast variety of diseases which can present with the same symptoms and signs as acute appendicitis. It is an important factor for delay in diagnosis. Many scoring systems are being used to reach a diagnosis within time and to reduce the rate of negative appendectomies.The purpose of this study was to compare both scoring systems (Alvarado and pediatric appendicitis scoring system) and to know which one is better to establish an early correct diagnosis of acute appendicitis in pediatrics, thus decreasing the morbidity and burden on hospital resources. Although many studies had been completed at the international level for comparing both of these scoring systems, the pediatric population in our region was still awaiting such an effort.So a prospective cohort study was designed. A total of 180 patients were recruited with 95% confidence level and 5% margin of error. Every enrolled patient was awarded clinical scores according to both the Alvarado scoring system and the pediatric appendicitis scoring system. Patients having a score of 7 or more by both scoring systems were considered “seven or more than seven group” and their appendectomies were performed and histopathology reports were reviewed. Patients having a score of 7 in one system and less than 7 in the other/both were considered “less than seven group” and were admitted in the ward for further clinical evaluation and observation.ResultsAt cutoff 7, the Alvarado score showed a sensitivity of 85.5%, specificity of 70%, PPV of 96.5%, NPV of 33.3%, and diagnostic accuracy of 84.11% while the pediatric appendicitis score showed a sensitivity of 93.8%, specificity of 70%, PPV of 96.8%, NPV of 53.8, and diagnostic accuracy of 91.59%.ConclusionThe pediatric appendicitis score (PAS) is superior in diagnosing acute appendicitis in the pediatric population than the Alvarado score as indicated by the values of diagnostic accuracy. So it can be a good diagnostic tool for pediatric patients presenting with clinical symptoms and signs of appendicitis.

P8 A single centre evaluation of risk prediction models and imaging modalities in acute appendicitis

ObjectivePatients with suspected appendicitis remain a diagnostic challenge. This study aims to validate risk prediction models and to investigate diagnostic accuracy of ultrasonography (US) and computed tomography (CT) in adults undergoing an appendicectomy.Materials and MethodsA retrospective case review of patients aged 16-45 undergoing an appendicectomy between January 2019 to January 2020 at a tertiary referral centre was performed. Primary outcomes were the accuracy of a high-risk appendicitis risk score and US and CT imaging modalities when compared to histological reports following appendicectomy.ResultsA total of 206 patients (107/205, 51.9% women) were included. Removal of histologically normal appendix was equally likely in men and women (13.1 versus 11.2%, relative risk 1.17, 95% c.i. 0.56 to 2.44; P =0.67). A high-risk appendicitis score correctly identified 84.0% (79/94) of cases in men and 85.9% (67/78) of cases in women. US was reported as equivocal in 85.7% (18/21) of low-risk women and 59.0% (23/39) of high-risk women. CT in low-risk women resulted in 25.0% (2/8) equivocal results whilst correctly diagnosing (5/6) or excluding (1/2) appendicitis in 75.0% of the total cohort (6/8). In high-risk women CT resulted in 3.8% (1/26) equivocal results whilst correctly detecting (22/23) or excluding (1/3) appendicitis in 88.5% of total high-risk patients (23/26).ConclusionsThis study suggests that risk prediction models may be useful in both women and men to identify appendicitis. US imaging gave high rates of equivocal results and should not be relied upon for the diagnosis of appendicitis but may be useful to exclude other differential diagnoses. CT imaging is a highly accurate diagnostic tool and could be considered in those at low-risk where clinical suspicion remains to reduce negative appendicectomy rates.

Bedside pressure-pain threshold algometry to measure abdominal tenderness in childhood appendicitis: A retrospective cohort study

IntroductionAbdominal wall tenderness and its localization are key diagnostic features of appendicitis. However, abdominal wall tenderness assessment is subjective, and its utility in the diagnostic discrimination of appendicitis is limited. The objective of this study is to assess whether measuring abdominal tenderness using algometry can improve the clinical assessment of children with suspected appendicitis. MethodsUsing a spring-gauge, pocket-size algometer, similar to a tire gauge, we measured abdominal wall pressure-pain thresholds and tenderness localization ratios in children with suspected appendicitis referred to one pediatric general surgeon. We correlated the results with the final diagnosis, standard diagnostic scores, and abdominal ultrasound. ResultsOf 557 children with suspected appendicitis, 421 (76%) had algometry measurements of whom 239 (57%) underwent appendectomy. Appendicitis was confirmed in 216 (90%); appendicitis prevalence 51%. Pressure-pain thresholds were significantly lower and tenderness localization ratios higher in appendicitis. The difference was greatest with perforation: maximum AUC 0.884 overall, in males AUC 0.935. During observation, pressure-pain thresholds decreased while tenderness localization ratio increased in appendicitis patients, signaling increasing tenderness and more precise localization for appendicitis. The reverse was observed for non-appendicitis patients. Localization ratios were superior to the two standard diagnostic appendicitis scores (Algometry AUC = 0.844; Alvarado AUC = 0.790, pediatric appendicitis score AUC = 0.760) and white blood cell count alone (AUC = 0.728). Algometry results yielded positive and negative predictive values up to 100%. ConclusionBedside measurements of abdominal wall tenderness outperformed individual clinical and laboratory parameters and appendicitis diagnostic scores in identifying acute appendicitis. If validated and given its ease, algometry has the potential for incorporation into clinical practice, documentation, and as a quantifiable tenderness measure for use in clinical research.

Diagnosis of acute appendicitis in children using urinary 5-hydroxy indol acetic acid and pediatric appendicitis score: A randomized control trial

PurposeAcute appendicitis in children represents a common problem. Diagnosis may be difficult due to lack of clinical data. Several scoring systems and laboratory investigations are used for diagnosis. This study aimed to build a model for diagnosis of acute appendicitis in children using urinary 5-hydroxyindoleacetic acid (5-HIAA) and pediatric appendicitis score. MethodsThis study was conducted on 191 children with suspicion of acute appendicitis. They were divided into two groups A and B. Children were evaluated in group A with pediatric appendicitis score, ultrasound, and CRP. In group B children were evaluated in the same manner of group A plus measuring of 5-HIAA. Resultsmean age was 13.3 ± 5.2 years. The mean duration of symptoms was 2.2 ± 1.4 days. The mean level of urinary 5-HIAA was 43.53 ± 24.05 in appendicitis patients in group B. In group A there were 65 cases who had appendectomy. Seventy-five children were operated in group B. Negative appendectomies were found in 13 and 7 cases in groups A and B respectively. Thirteen cases were readmitted in group A with diagnosis of acute appendicitis while seven cases were readmitted in group B. ConclusionThis combination of urinary 5-HIAA and pediatric appendicitis score builds a model for diagnosis of acute appendicitis in children. This model improves the accuracy of diagnosis of acute appendicitis, reduces both the incidence of negative appendectomies and the incidence of readmission or missed cases in children.

Результаты Pediatric Appendicitis Score в дифференциальной диагностике острой неспецифической боли в животе у детей: возраст имеет значение

Acute nonspecific abdominal pain in children is the most common problem requiring differential diagnosis with acute appendicitis. Scales for integrated assessment of individual symptoms and their combinations have been proposed and are constantly being developed that allow predicting the likelihood of acute appendicitis. Purpose to assess diagnostic value of Pediatric Appendicitis Score (PAS) in groups of children in different ages. Materials and methods. 374 children aged 4 to 15 years with acute abdominal pain were evaluated in prospective randomized blinded study. Statistical analysis: ROC – curves, specificity and sensitivity, positive and negative predictive values; Kullback criteria; logistic regression analysis; discriminant analysis. Results. Detection frequency and diagnostic significance of the PAS scale predictors as well as obtained results by using the Pediatric Appendicitis Score depend on children age significantly. In terms of diagnosis of acute appendicitis, the PAS scale shows the best results in older children. Conclusions. Results of Pediatric Appendicitis Score depend on children ages due to different diagnostic value of predictors used in the PAS scale. Pediatric surgeons should keep in your mind these data. Modification of the scale is required taking into account the patient’s age. Further analysis of the issue of PAS using is needed. The research was carried out in accordance with the principles of the Helsinki Declaration. The study protocol was approved by the Local Ethics Committee of these Institutes. The informed consent of the patient was obtained for conducting the studies. The authors declare no conflicts of interests. Key words: acute appendicitis, children, diagnosis, PAS scale.

Clinical Prediction Score for Ruptured Appendicitis in ED.

Background Ruptured appendicitis has a high morbidity and mortality and requires immediate surgery. The Alvarado Score is used as a tool to predict the risk of acute appendicitis, but there is no such score for predicting rupture. This study aimed to develop the prediction score to determine the likelihood of ruptured appendicitis in an Asian population. Methods This study was a diagnostic, retrospective cross-sectional study in the Emergency Medicine Department of Ramathibodi Hospital between March 2016 and March 2018. The inclusion criteria were age >15 years and an available pathology report after appendectomy. Clinical factors included gender, age>60 years, right lower quadrant pain, migratory pain, nausea and/or vomiting, diarrhea, anorexia, fever>37.3°C, rebound tenderness, guarding, white blood cell count, polymorphonuclear white blood cells (PMN) > 75%, and pain duration before presentation. The predictive model and prediction score for ruptured appendicitis were developed by multivariable logistic regression analysis. Result During the study period, 480 patients met the inclusion criteria; of these, 77 (16%) had ruptured appendicitis. Five independent factors were predictive of rupture, age>60 years, fever>37.3°C, guarding, PMN>75%, and duration of pain>24 hours to presentation. A score >6 increased the likelihood ratio of ruptured appendicitis by 3.88 times. Conclusion Using the Ramathibodi Welawat Ruptured Appendicitis Score (RAMA WeRA Score) developed in this study, a score of >6 was associated with ruptured appendicitis.

Magnetic Resonance Imaging Provides Useful Diagnostic Information Following Equivocal Ultrasound in Children With Suspected Appendicitis [Formula: see text

In Canada, ultrasonography is the primary imaging modality for children with suspected appendicitis, yet equivocal studies are common. Magnetic resonance imaging provides promise as an adjunct imaging strategy. The primary objective of this study was to determine the proportion of children with suspected appendicitis and equivocal ultrasound where magnetic resonance imaging determined a diagnosis. A prospective consecutive cohort of children aged 5-17 years presenting to a tertiary pediatric Emergency Department with suspected appendicitis were enrolled. Participants underwent diagnostic and management strategies according to our local suspected appendicitis pathway, followed by magnetic resonance (Siemens Avanto 1.5 Tesla) imaging. Sub-specialty pediatric radiologists reported all images. Magnetic resonance imaging was performed in 101 children with suspected appendicitis. The mean age was 11.9 (SD 3.4) years and median Pediatric Appendicitis Score was 6 [IQR 4,8]. Ultrasonography was completed in 98/101 (97.0%). Of 53/98 (54.1%) with equivocal ultrasound, magnetic resonance imaging provided further diagnostic information in 41 (77.4%; 10 positive, 31 negative; 12 remained equivocal). Secondary findings of appendicitis on magnetic resonance imaging in children with equivocal ultrasound included abdominal free fluid (24, 45.3%), peri-appendiceal fluid (12, 22.6%), intraluminal appendiceal fluid (9, 17.0%), fat stranding (8, 15.1%), appendicolith (2, 3.8%), and peri-appendiceal abscess (1, 1.9%). The observed agreement between magnetic resonance imaging results and final diagnosis was 94.9% (kappa = 0.89).

A single centre evaluation of risk prediction models and imaging modalities in acute appendicitis.

Patients with suspected appendicitis remain a diagnostic challenge. The aim of this study was to validate risk prediction models, and to investigate diagnostic accuracy of ultrasonography and computed tomography (CT) in adults undergoing appendicectomy. A retrospective case review was performed of patients aged 16-45 years having an appendicectomy between January 2019 and January 2020 at a tertiary referral centre. Primary outcomes were the accuracy of a high risk appendicitis risk score and ultrasonography and CT imaging modalities compared with histological reports following appendicectomy. A total of 206 patients (52% female) were included in the study. Removal of a histologically normal appendix was equally likely in men and women (13.1% vs 11.2% respectively, relative risk: 1.17, 95% confidence interval: 0.56-2.44, p=0.674). A high risk appendicitis score correctly identified 84.0% (79/94) of cases in men and 85.9% (67/78) of cases in women. Ultrasonography was reported as equivocal in 85.7% (18/21) of low risk women and 59.0% (23/39) of high risk women. CT correctly detected or excluded appendicitis in 75.0% (6/8) of low risk women and 88.5% (23/26) of high risk women. This study suggests that risk prediction models may be useful in both women and men to identify appendicitis. Ultrasonography gave high rates of equivocal results and should not be relied on for the diagnosis of appendicitis. CT is a highly accurate diagnostic tool and could be considered in those at low risk where clinical suspicion remains to reduce negative appendicectomy rates.

Diagnostic Value of Clinical Prediction Scores for Acute Appendicitis in Children Younger than 4 Years.

Acute appendicitis can be difficult to diagnose, especially in children < 4 years old. The aim of the present study was to assess the diagnostic value of Alvarado score (AS), appendicitis inflammatory response (AIR) score, and pediatric appendicitis score (PAS) in children younger than 4 years. All children younger than 4 years who underwent appendicectomy between 2005 and 2019 were included retrospectively. The diagnostic performance of the scores was analyzed using the area under the receiver-operating characteristic (ROC) curve and by calculating the diagnostic performances at optimal criterion value cutoff points. In this study, 100 children were included (58 boys and 42 girls) with a median age of 39.5 (12-47) months. Ninety children were diagnosed with pathologically proven acute appendicitis. The area under ROC curve of AS was 0.73, AIR score was 0.79, and PAS was 0.69 (p > 0.05, respectively). In children with low risk of acute appendicitis, negative predictive values were 75.0% for AS, 50.0% for AIR score, and 66.7% for PAS (p < 0.05, respectively). The positive predictive values in children with high risk of acute appendicitis were of 92.7% for AS, 92.6% for AIR score, and 93.6% for PAS (p > 0.05, respectively). AS, AIR score, and PAS plus positive ultrasonography have 0.58, 0.49, and 0.88 area under ROC curve. The three scores can be of assistance in the suspicion of acute appendicitis. PAS markedly improved combined with positive ultrasonography, but none can be used in setting the diagnosis of acute appendicitis in young children.

Comparison of major appendicitis scoring systems on the clinical-histopathological correlation

Aim: We aimed to investigate the predictive value of the four most popular scoring systems, such as Modified Alvarado, Raja Isteri Pengiran Anak Saleha Appendicitis, Tzanakis, and Lintula, for histopathologically proven acute, phlegmonous, and gangrenous/perforated appendicitis. Materials and Methods: We retrospectively reviewed the results of 239 patients who underwent appendectomy between 2016 and 2019 in our department. The patients' demographic data, surgery method, histopathological results of the specimens (uncomplicated acute appendicitis, phlegmonous, and gangrenous/perforated appendicitis) were recorded. The predictivity of Modified Alvarado, Raja Isteri Pengiran Anak Saleha Appendicitis, Tzanakis, and Lintula scoring systems according to the histopathological results was compared.Results: The modified Alvarado scoring system showed statistically significant efficacy in the preoperative distinction of acute, phlegmonous, and gangrenous/perforated appendicitis. Although the Raja Isteri Pengiran Anak Saleha Appendicitis and Tzanakis score systems are effective in acute and gangrenous/perforated differentiation, they did not show statistically significant efficacy between acute and phlegmonous appendicitis. The Lintula scoring system was the weakest among the four and did not show statistically significant efficacy in the distinction of all three diagnoses.Conclusion: The diagnosis of acute appendicitis is easier with the use of scoring systems. Scoring systems can also help signal advanced stage and complicated forms of acute appendicitis, such as phlegmonous and gangrenous/perforated appendicitis. The modified Alvarado was the most correlated scoring system with histopathological results.