Diagnosis Of Acute Appendicitis In Children Research Articles

Modified Alvarado and Samuel scores: Contribution to the diagnosis of acute appendicitis in the pediatric acute and emergency department

Introduction Acute abdominal pain is a common complaint among pediatric patients. Surgical emergencies, particularly acute appendicitis (AA), evoke significant concern due to the challenges associated with its diagnosis. Objectives This study aimed to evaluate the contribution of modified Alvarado and Samuel scores (pediatric appendicitis scoring systems) to the diagnosis of AA in children who attended our acute and emergency department. Study Population and Methods Children aged 3 to 16 years who presented to the acute and emergency department with acute abdominal pain were included after obtaining parental consent and Ethics Committee approval. Data on the patient’s age, sex, body temperature, history of bowel habits, trauma, weight loss, chronic gastrointestinal disease, etc., were collected. The modified Alvarado and Samuel scores were calculated, and children were classified into three groups: G1 (score <4), G2 (≥4 score <7), and G3 (score ≥7). The diagnostic value of both scores was assessed by calculating their positive predictive value (PPV), negative predictive value (NPV), sensitivity, specificity, positive likelihood ratio (PLR), and negative likelihood ratio (NLR). Children with known chronic inflammatory bowel disease, obvious sepsis, and incomplete case records were excluded. Results Of the 90 children recruited for this study, only 87 were included (49 boys, 38 girls, sex ratio: 1.3:1). The overall mean age of the study population was 9.3 years, and the mean ages per group were 9.25 years (G1), 10.3 years (G3), 9.5 years (G3-1), and 7.25 years (G3-2). Of the 87 children, 69 (79%) experienced abdominal pain attributed to a medical cause, and 18 (21%) required surgery [of whom 16 received early intervention, while 2 (G3-1 subgroup) received the intervention after 24 hours of observation]. Of the 16 patients who received early intervention, 6 (38%) who underwent immediate surgery had perforated appendicitis, 4 had suppurated appendicitis, and 6 had simple inflammatory appendicitis. For G3 patients, Alvarado score showed a PPV, an NPV, a sensitivity, a specificity, a PLR, and a NLR of 91.7%, 98%, 91.7%, 98%, 45.5, and 0.09, respectively. For Samuel score, the values were 93%, 98%, 93%, 98%, 46, and 0.08, respectively. The majority of patients with purulent and perforated appendicitis (except 1, score 3) belonged to G3, of whom 1 had a false-positive score (score ≥7) and another had a false-negative score (score 3). Four patients in G3 required abdominal tomodensitometry. Conclusion The modified Alvarado and Samuel scoring system is a valuable tool for diagnosing AA in children seeking care at the acute and emergency department.

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

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. 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. 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%. In case of suspicion of AA, US may be the first choice because it is inexpensiveand 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.

Сучасні принципи діагностики та лікування гострого апендициту в дітей

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.

Diagnostic Value of Serum Urokinase-Type Plasminogen Activator Receptor in Children With Acute Appendicitis.

Acute appendicitis (AA) is the most common surgical emergency in children. The accurate and timely diagnosis of AA in children can be challenging, and delayed diagnosis rates have been reported to range from 5.9% to 27.6%. Although combining clinical history and repeated physical examination with laboratory tests and radiographic imaging modalities help reach the diagnosis, novel biomarkers can support the surgeons' decision as well. The aims of this study were to evaluate a new plasma marker, urokinase-type plasminogen activator receptor (uPAR), to improve diagnostic accuracy in AA patients, and to determine a cutoff value of uPAR, which can safely include/exclude the diagnosis of AA. We conducted a prospective study of children who underwent surgery for AA. Patients were categorized into the following 3 groups: group 1, controls consisted of 32 healthy volunteers; group 2, patients underwent surgery for nonperforated AA (n = 35); and group 3, patients underwent surgery for perforated AA (n = 21). Blood was sampled from group 1 at the admission and from group 2 and 3 before appendectomy. Serum uPAR, white blood cell count, absolute neutrophil count (ANC), and C-reactive protein concentrations were measured. Urokinase-type plasminogen activator receptor, ANC, and white blood cell count values were significantly higher in group 2 and 3 than group 1, but there was no significant difference between group 2 and 3. C-reactive protein values were significantly higher only in group 3 than other groups. The cutoff value for uPAR is 2.2 ng/mL with sensitivity of 85.7% and specificity of 84.3% and ANC is 5900 cells/mm with sensitivity of 91.1% and specificity of 96.9% to diagnose appendicitis. The specificity was 81.3% and sensitivity was raised to 98.2% when evaluated together. The incorporation of uPAR count and ANC could be a strong predictor of AA in children.

Neutrophil-to-lymphocyte ratio in pediatric 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.

Evaluation of proadrenomedullin as a diagnostic or prognostic biomarker of acute appendicitis in children

IntroductionA delay in the diagnosis of acute appendicitis (AA), with the added complication of symptoms that mimic other self-limited causes of abdominal pain, can lead to an increase in ruptured appendices and morbimortality. None of the serum biomarkers evaluated to date have shown a predictive value for early diagnosis. ObjectiveThe objective of this study was to evaluate the usefulness of proadrenomedullin (MR-proADM) in the diagnosis of AA in children presenting with acute abdominal pain. MethodsA single-center prospective observational study was conducted in 136 children who presented to the emergency department with suspected AA. ResultsForty-four (32.5%) children had AA, and 9 (20.5%) had perforated appendicitis. The mean concentration of MR-proADM was significantly higher in children with AA than in children with nonspecific abdominal pain (NAP) (0.54 nmol/L; 95% confidence interval, 0.46-0.55 and 0.37 nmol/L; 95% confidence interval, 0.35-0.40, respectively). Performance characteristics of MR-proADM alone were not optimal. However, after combining best cutoff points, the combination of a C-reactive protein level of <0.3 mg/dL and a MR-proADM level of <0.34 nmol/L showed 100% sensitivity and negative predictive value, with 61% specificity. ConclusionsAlthough MR-proADM values are higher in children with AA than in children with nonspecific abdominal pain, these values do not help in the early diagnosis of AA. The combination of low C-reactive protein and low MR-proADM levels is useful for the identification of children with a low risk of AA.

Relative Value of Clinical, Laboratory and Imaging Tools in Diagnosing Pediatric Acute Appendicitis

Aim of the study was to evaluate the relative value of the tools used to diagnose suspected acute appendicitis (AA) in children. A retrospective review of data from 1 848 children admitted to the Pediatric Surgery Department between 2004 and 2008 in our university-affiliated medical center was conducted. A total of 780 children underwent appendectomy at first presentation. Of these patients, 75 children required removal of their appendix during laparotomy for other reasons and 19 had appendectomy following peri-appendicular abscess and were excluded from the study. The study included 686 children (2-16 years of age) with presumed AA managed by appendectomy. Clinical, laboratory, and imaging data were collected and compared to pathology results. Of the 686 children who underwent surgery for suspected AA, 34 (5%) had a normal appendix (negative appendectomy rate). No statistical differences were found between normal and AA groups with regard to vomiting, diarrhea, pain duration, and peritoneal signs on admission. Children in the AA group were younger (10.9±3.2 vs. 12.1±2.3 years, p=0.004), had higher fever (36.9±0.7°C vs. 37.4±0.8°C, p=0.004), WBC (14.8±4.8 vs. 10.5±4.6×103/mL, p<0.0005), and neutrophil counts (77.2±11.1% vs. 64.0±15.9%, p<0.0005) on admission, and larger appendicular diameters on ultrasound (US) examination (0.9±0.2 cm vs. 0.7±0.08 cm, p<0.0005). The parameters with the highest positive predictive values for AA were WBC (>10×10 (3)/mL), neutrophil (>66%) count on admission (positive predictive value [PPV]=0.971 and 0.975, respectively), and appendicular diameter on US (>6 mm; PPV=0.968). These 3 parameters combined had a PPV of 0.991. The results of laboratory tests (WBC, neutrophils) and imaging (US) contributed far more than clinical signs and symptoms (pain duration, vomiting, diarrhea, fever, and peritoneal signs at first physical examination) to the correct diagnosis of AA in children. When these 3 parameters were positive, the probability of a false positive (normal appendix) was only 1%. The contribution of US was particularly high as it was used primarily in patients in whom the diagnosis was in doubt and its results matched the final diagnosis better than diagnoses based on clinical signs and symptoms alone. It provides the additional benefit of no radiation exposure.

Evaluation of using Alvarado score and C-reactive protein in diagnosing acute appendicitis in children

Acute appendicitis (AA) remains a diagnostic challenge in children, despite ongoing researches. With an aim to facilitate making diagnosis of AA many scoring systems have been created; among them Alvarado score is the most popular. C-reactive protein (CRP) has proven significance for diagnosing AA in adults, but not in children. The aim of this study was to evaluate significance of Alvarado score, as well as CRP values, in making diagnosis of AA in children. This prospective six-month study was performed on 257 patients under the age of 15, admitted for acute abdominal pain in the Clinic of Pediatric Surgery and Orthopedics in the Clinical Centre of Nis. Alvarado score and CRP values were determined on admission and compared with final diagnosis on discharge. The patients were divided into two groups: group I--non operated patients with abdominal pain (n=184) and group II--operated on patients for appendectomy (n=73). Values of Alvardo score were statistically significantly different between groups (group I: 4.9 +/- 1.21, group II: 8.55 +/- 1.32). Also, our results showed significantly high values of CRP measured in operated children (group I: 8.17 +/- 4.7 mg/L, group II: 38 +/- 26 mg/L). Values of validity parameters for Alvarado score were: sensitivity 90%, specifity 80%, positive predictive values 87%; for CRP 95%, 70% and 80%, respectively. Alvarado score and CRP are very useful adjuvant diagnostic tool for AA to a less experienced surgeon. High values of Alvarado score and CRP cannot be ignored neither at the same time, used as the sole diagnostic method for discriminating children with AA.