Perforated Appendicitis Group Research Articles

Hyperfibrinogenemia and hyponatremia as predictors of perforated appendicitis in children: A retrospective cohort study

The aim of this study was to investigate the predictive value of hyperfibrinogenemia and hyponatremia for perforated appendicitis in children. A retrospective review of 521 pediatric patients (≤ 15years) with acute appendicitis confirmed by histopathology from January 2017 to December 2020 was performed. Patients were divided in two groups, those with non-perforated (n = 379; 73%) and perforated appendicitis (n = 142; 27%). The serum values of sodium and fibrinogen were taken before surgery. We performed the receiver operating characteristic analysis for the two biochemical markers. The sensitivity, specificity, positive and negative predictive values for perforated appendicitis in the presence of hyponatremia and hyperfibrinogenemia were calculated. Hyperfibrinogenemia (≥ 4.0g/L) was found in 58.45% of perforated appendicitis and 104 of 142 (73.34%) children with perforated appendicitis had hyponatremia (≤ 135mmol/L). The perforated appendicitis group had a higher mean fibrinogen concentration (P = 0.001). There was a statistically significant difference in mean serum sodium levels between the perforated appendicitis and non-perforated appendicitis groups (P = 0.016). Receiver operating characteristic curve analysis for fibrinogen, sodium and combination of the both markers shown the combination had the largest area under the curve in identifying children with perforated acute appendicitis (0.858) (95% CI, 0.82-0.90) compared with fibrinogen (0.815) (95% CI, 0.77-0.86) and sodium 0.818 (95% CI, 0.78-0.86) alone. Furthermore, the combination of both markers had the best positive and negative predictive value for appendix perforation compared to fibrinogen and sodium. Hyponatremia and/or hyperfibrinogenemia are excellent markers for predicting perforated appendicitis in children. We propose that plasma sodium and/or fibrinogen concentrations be utilized as a supplementary to guide individual treatment decisions in children with appendicitis, such as surgery timing and nonoperative management options.

Role of Immature Granulocyte Count and Percentage in The Differential Diagnosis of Appendicitis

Objective: Acute appendicitis is one of the most important and widely performed emergent surgery in pediatric surgery practice. Diagnosis of appendicitis in children is more challenging compared to adults. The immature granulocyte percentage (IG%) is recently investigated laboratory parameter for detection of inflammation severity in adult population . The aim of the study was determination of IG count and percentage role in early detection of pediatric acute appendicitis. Materials and Methods: The data of patients who applied to Emergency Room with the complaint of abdominal pain and who were operated with a pre-operative diagnosis of acute appendicitis between January 2021 and December 2022 retrospectively reviewed from hospital records. Patients under 18 years, operated due pre-operative diagnosis of acute appendicitis and who have hemogram included in the study. Results: One hundred eight patients included in the study. Fourty-eight patients were in the acute appendicitis group, 9 patients were in the perforated appendicitis group, and 53 patients were in the control group. The mean IG % of was 0.31±0.37 and 0.96±5.1 in appendicitis and control group patients, respectively. No significant difference was found between appendicitis patients and control group in terms of IG number and percentage. No statistically significant difference was found between acute and perforated appendicitis in terms of IG number and IG%. Conclusion: IG number and IG% did not provide any additional benefit and is not a conclusive biomarker for clinician in determination of acute appendicitis. A combination of anamnesis, physical examination and laboratory test remains gold standard for diagnosis of acute appendicitis.

The role of IL-6, thiol–disulfide homeostasis, and inflammatory biomarkers in the prediction of acute appendicitis in children: a controlled study

This study aimed to examine the diagnostic value of IL-6, thiol-disulfide homeostasis, complete blood count and inflammatory biomarkers in the prediction of acute appendicitis in children. The study was designed as a prospective and controlled study in children-the study was conducted at a tertiary referential university hospital between May 2020 and April 2021. Patients were divided between study groups and one control group (CG): 1: confirmed acute appendicitis group (AAP); 2: perforated appendicitis group (PAP); and 3: non-specified abdominal pain (NAP). The age and gender of the patients were determined. The following listed laboratory parameters were compared between groups: TOS: total oxidative status, TAS: total antioxidant status, OSI: oxidative stress index, TT: total thiol, NT (µmol/L): native thiol, DIS: disulfide, IL-6: interleukin 6, TNF-a: tumor necrosis factor-alpha, WBC: white blood cell, NEU: neutrophil, NEU%: neutrophil percentage, LY: lymphocyte, LY%: lymphocyte percentage, PLT: platelet, MPV: mean platelet volume NLR: neutrophil lymphocyte ratio, CRP: C-reactive protein, LCR: lymphocyte CRP ratio, and serum lactate. The TOS level of the PAP group was found to be significantly higher than that in the AAP, NAP and control groups (p = 0.006, < 0.001 and p < 0.001). TAS, TT, and NT levels in the PAP group were significantly lower than those in the AAP, NAP and control groups. OSI was significantly higher in the PAP group than in the other groups. The TT and NT levels of the NAP group were both similar to those of the control group. Serum DIS level was similar between the AAP and PAP groups, AAP and NAP groups, and NAP and control groups. Serum IL-6 and TNF-α levels were found to be significantly higher in the PAP group compared to those in all groups. The WBC, NEU, and NEU% values were found to be significantly higher in the PAP group than those in the NAP and control groups, while LY and LY% values were found to be significantly lower. PAP and AAP groups were found to be similar in terms of WBC, NEU, LYM, NEU%, and LYM% values. PLT and MPV values and serum lactate values did not show a significant difference between the groups. NLR was similar in the AAP and PAP groups. A significant increase in CRP versus a decrease in LCR was detected in the PAP group compared to that in the AAP group. Multivariate analysis demonstrated that only IL-6 has significant estimated accuracy rates as 80% for the control group, 78.8% for AAP, 96.9% for PAP, and 81.6% for NAP. Rather than AAP, PAP caused significantly higher oxidative stress (increased TOS and OSI), and lower antioxidation capacity (decreased TT and NT). IL-6 levels can provide a significant stratification. Nevertheless, simply detecting WBC or CRP is not enough to distinguish the specific pathology in acute appendicitis and related conditions.

Investigation of Serum Interleukin 6, High-Sensitivity C-Reactive Protein and White Blood Cell Levels during the Diagnosis and Treatment of Paediatric Appendicitis Patients Before and during the COVID-19 Pandemic.

In this study, we prospectively investigated changes in serum interleukin-6 (IL-6), high-sensitivity C-reactive protein (hsCRP) and full white blood cell (WBC) counts during the diagnosis and treatment of paediatric patients with appendicitis. We also investigated the effects of the COVID-19 pandemic on the diagnosis and treatment processes of paediatric appendicitis patients. A non-perforated appendicitis group (n = 110), a perforated appendicitis group (n = 35) and an appendicitis + COVID-19 group (n = 8) were formed. Blood samples were taken upon admission and every day until the three studied parameters returned to normal values. To investigate the effects of the COVID-19 pandemic on paediatric appendicitis patients, the perforated appendicitis rates and the times from the onset of the first symptoms to the operation before and during the pandemic were compared. WBC, IL-6, and hsCRP dropped below the upper limits on the second postoperative day in the non-perforated appendicitis group, four to six days postoperatively in the perforated appendicitis group, and three to six days postoperatively in the appendicitis + COVID-19 group. These parameters were not within normal range in patients who developed complications during follow-up. The time from the onset of abdominal pain to the surgery was significantly longer during than before the pandemic in both the non-perforated appendicitis group and the perforated appendicitis group. Our results show that WBC, IL-6, and hsCRP are useful laboratory parameters that can complete clinical examinations in the diagnosis of appendicitis in paediatric patients and the identification of complications that may develop postoperatively.

Şok İndeksi ve GFR’nin Perfore Apandisit Ayırıcı Tanısındaki Klinik Önemi

Aim: The aim of the study is to investigate whether the shock index (SI) and glomerular filtration rate (GFR) have significance in differentiating acute appendicitis from complicated perforated acute appendicitis. Materials-Methods: Patients were searched retrospectively on the hospital database. Age, gender, C-reactive protein (CRP), leukocyte (WBC), total bilirubin (T.BIL), urea, creatinine, pulse (NBZ), and arterial blood pressure (TA) values of the patients were searched retrospectively on the hospital database and a database was created by using these patient variables. GFR and SI were calculated by using these data. The surgical notes about patients were reviewed retrospectively, and they were divided into two groups, namely perforated appendicitis and non-perforated appendicitis. The data were analyzed to investigate whether GFR and SI were effective in predicting perforation. Results: It was observed that NB/TA value had more frequent pathological findings in patients with perforated appendicitis (p&amp;lt;0.001). It was found that age (p=0.001), CRP (p&amp;lt;0.001), WBC (p&amp;lt;0.001), T. BIL (p=0.002), NB (p=0.017), and NB/TA (p&amp;lt;0.001) values of the patients in the perforated appendicitis group were higher than those of the patients in the normal appendicitis group, while GFR (p&amp;lt;0.001) and TA (p&amp;lt;0.001) values were lower (p&amp;lt;0.05). Conclusion: It is thought that SI and GFR may be a prognostic parameter for showing both perforation and the associated increased mortality rate.

The Diagnostic Value of Presepsin in Acute Appendicitis and Reference Ranges for Healthy Children.

This study aimed to investigate the diagnostic value of presepsin, a new inflammatory marker for paediatric appendicitis, and to determine a reference range of presepsin for children. This single-center prospective study was conducted in our paediatric emergency department between 1 February 2021 and 1 July 2021. Patients aged 0-18 years diagnosed with acute appendicitis, which was pathologically confirmed, and healthy volunteers in the same age group were included in the study. Serum presepsin levels were analysed using an enzyme-linked immunosorbent assay reader. In addition to presepsin, other acute-phase reactants, paediatric appendicitis scores and imaging methods were evaluated. There were 94 patients in the acute appendicitis group and 102 healthy volunteers in the control group. Median values were compared between the two groups, and no statistically significant differences were found (p = 0.544). In addition, no statistically signivficant differences in presepsin levels were found between the acute and perforated appendicitis groups (p = 0.344). The median (IQ1-IQ3) reference range for presepsin in healthy children was 0.9950 (0.7575-1.610) ng/mL. Presepsin is not a suitable marker for the diagnosis of acute appendicitis. We observed that serum presepsin levels were not elevated in paediatric appendicitis, which is a local infection, in contrast to previous studies.

Evaluation of the appendectomy cases performed under emergency conditions during the COVID-19 pandemic and discussed with the pathology reports.

The aim of this study is to examine the cases underwent appendectomy during the COVID-19 pandemic and to discuss the pathology reports of patients. During the COVID-19 pandemic, the pathological reports of the appendectomy materials of 588 patients over the age of 15 who applied to the emergency department between January 1, 2020, and June 1, 2021, were examined. A total of 565 patients with a diagnosis of acute (AA), subacute (SA), or perforated appendicitis (PA) were included and divided into three groups according to diagnosis. Twenty-three patients were excluded from the study due to other pathologies. The age, gender, duration of pain, ASA score, operational technique, operation time, Clavien-Dindo score, hospitalization time, post-operative complications, pre- and post-operative PCR and thoracic tomography findings in suspected cases of COVID-19, and laboratory and radiological findings of patients were retrospectively analyzed. Of 565 patients diagnosed with appendicitis, 464 (82.1%) had AA, 35 (6.2%) SA, and 66 (11.7%) PA. The median age of the PA group was higher than in the AA group (p=0.0139). The incidence of diabetes mellitus in the PA group and of asthma in the SA group were highest among other groups (p=0.004 and 0.0037, respectively). The duration of pain was longer in the SA and PA groups than the AA group (p<0.0001), therefore, the patients applied to hospital later than the acute group. The rate of thorax CT-positive scans was 1.6% in patients suspected for COVID-19 (p=0.066). While laparoscopic surgery was preferred over 70% in all groups, the rate of conventional surgery (21.1%) in the AA group was highest and of transition from laparoscopic to open surgery was highest in the PA group (10.6%) (p<0.0001). Hospitalization duration was longest in the PA group (p<0.0001). COVID-19 pandemic not only changes all routines of social life but also complicates the treatment and manage-ment of cases with AA symptoms applied to hospital under emergency conditions. Follow-up of the appendectomy specimen is crucial in terms of excluding other pathologies.

Histopathological examination of acute appendicitis tissue in children during the COVID-19 pandemic

In this study, we prospectively investigated the histopathological features of the removed appendix tissue in pediatric patients who were operated on with the preliminary diagnosis of appendicitis. A catarrhal appendicitis group (n=43), a phlegmonous appendicitis group (n=28), a gangrenous appendicitis group (n=19), a perforated appendicitis group (n=35), and an appendicitis +COVID-19 group (n=7) were formed. The control group consisted of 21 children. A section of each patient's appendix tissue from the part with the highest diameter was taken for histopathological examination. The sections were routinely stained with hematoxylin and eosin (H &amp; E). The two pathologists evaluated all H &amp; E sections in a light microscope. The evaluation results were analyzed statistically. No significant differences in age and gender were found between all groups. The results of neutrophil and lymphocyte counts in all tissue layers of all groups were significantly different. Neutrophil count in the mucosa and muscularis propria in the appendix tissues of the control group were found to be zero. Among all groups, the highest number of neutrophil counts in the mucosa and muscularis propria were found in the perforated group. Among all groups, the highest number of lymphocyte counts in mucosa and muscularis propria were found in the Covid-19 group. The mucosal erosion, intraluminal neutrophils, and reactive lymphoid hyperplasia were negative in all samples in the control group. Neutrophil accumulation in the mucosa and muscularis propria layers in appendix tissue together with other inflammation findings are important in the histopathological diagnosis of appendicitis. In patients with Covid-19 infection, appendicitis may occur, in which case, severe accumulation of lymphocytes appears in the mucosal layer in addition.

Laboratory markers used in the prediction of perforation in acute appendicitis.

In this study, we aimed to evaluate the laboratory markers used in the diagnosis of acute appendicitis (AA) and present the parameters that can be used to predict acute perforated appendicitis. The cases who underwent an appendectomy in our clinic between September 2018 and March 2020 were evaluated retrospectively. A total of 530 patients who met the study criteria were included in the study. Patients were divided into two groups according to the presence of an intraoperative perforation. Non-complicated appendicitis patients formed Group-1, and perforated appendicitis patients formed Group-2. The demographic, clinical, and laboratory characteristics of the patients were compared. The number of non-complicated patients in Group 1 was 443, while there were 87 (16.4%) patients in Group 2 who had perforated appendicitis. The mean age of the patients in the normal appendicitis group was 29.90±10.51 years, and the mean age of the patients in the perforated appendicitis group was 36.32±14.58 years. In the normal appendicitis group, 257 (58%) of the patients were male, 186 (42%) were female, while in the perforated appendicitis group, 38 (43.7%) were male, 49 (56.3%) were female. In the perfo-rated appendicitis group, white blood cell (WBC) value was 16.19±4.71 (p<0.001), C-reactive protein (CRP) value was 146.28±113.59 (p<0.001), total bilirubin value was 0.71±0.36 (p<0.001), and neutrophil-lymphocyte ratio (NLR) was 10.85±6.25 (p<0.001). We believe that the WBC, total bilirubin, CRP, and NLR values obtained within this study, which is tested in the rapid and easily accessible blood tests in routine examinations that can contribute to the prediction of perforation.

SB7H3 in Children with Acute Appendicitis: Its Diagnostic Value and Association with Histological Findings.

Background Several efforts have been made to find out a valuable marker to assist the diagnosis and differentiation of gangrenous/perforated appendicitis. We aimed to determine the diagnostic capacity of soluble B7H3 (sB7H3) in acute appendicitis (AA) and its accuracy as a predictor of the severity of appendicitis. Methods 182 children were allocated into four groups as follows: control group (CG, 90), simple appendicitis (SA, 12), purulent appendicitis (PA, 49), and gangrenous appendicitis (GA, 31). Prior to appendectomy, blood was collected and sent for analysis of routine examination and cytokines (sB7H3 and TNF-α). We compared values of all measured parameters according to histological findings. Furthermore, we assigned AA patients into the nonperforated appendicitis group and the perforated appendicitis group. The diagnostic effects of significant markers were assessed by ROC curves. Results Only the levels of CRP, FIB, and sB7H3 had a remarkable rising trend in AA-based groups, while differences in the levels of CRP and FIB between simple appendicitis and purulent appendicitis were not statistically significant. In addition, sB7H3 was found as the only marker in children with AA, which was markedly associated with the degree of histological findings of the appendix. Furthermore, sB7H3 had a high diagnostic value in predicting AA and complex appendicitis (PA+GA) in children. However, the diagnostic performance of sB7H3 for distinguishing PA from GA was not remarkable. Additionally, only the levels of CRP and sB7H3 were statistically different between the nonperforated appendicitis group and the perforated appendicitis group. The diagnostic performance of CRP and sB7H3 could not merely predict perforation of AA in children; however, the diagnostic performance was improved after combination. Conclusions sB7H3 could be used as a valuable marker to predict the presence of AA and complex AA in children. However, the diagnostic value of sB7H3 to predict gangrenous/perforated appendicitis was not found to be remarkable. The combination of sB7H3 and CRP might improve the prediction of perforated appendicitis.

Role of Hyperbilirubinemia as a Diagnostic Tool to Predict Gangrenous/Perforated Appendicitis: An Observational Study

Background: Elevation in serum bilirubin was reported recently, but the importance of the raised total bilirubin has not been stressed in acute appendicitis and appendicular perforation. The aim of the study was to establish the role of hyperbilirubinemia as a new diagnostic tool to predict gangrenous/perforated appendicitis. Subjects and Methods: This was a prospective observational study, which was conducted at the Gujarat Adani Institute of Medical Science, Bhuj, Kutch, Gujarat, India. A total of 100 patients clinically diagnosed as appendicitis from August 2018 to August 2019 at Gujarat Adani Institute of Medical Science, Bhuj, Kutch, Gujarat, India. Patients were clinically evaluated by detailed history, routine examination on initial contact with patients and the routine investigations as per surgery and anesthesia requirements with inclusion of serum total bilirubin. Based on histopathological examination patients will be categorized as positive (acute appendicitis with perforation and/or gangrene) and negative (acute appendicitis without perforation or gangrene). Results: Out of 100 patients, 20 were managed conservatively (mass formation) and was called for interval appendectomy after 6 weeks. In acute catarrhal appendicitis group 47 patients showed normal total bilirubin levels, whereas 8 patients showed increase in levels of total bilirubin. In gangrenous appendicitis group all 10 patients showed elevated serum total bilirubin levels In perforated appendicitis group consisted of 15, 11 patients showed elevated serum bilirubin levels and 4 patients showed normal total bilirubin levels. Conclusion: Serum bilirubin is easily available test and cheap and can be estimated from the sample of blood drawn for routine blood investigations.

The role of C-reactive protein to lymphocyte ratio in the differentiation of acute and perforated appendicitis.

This study aimed to investigate the superiority of C-reactive protein (CRP) lymphocyte ratio (CLR) in acute appendicitis (AA) and perforated appendicitis (PA) compared to routine laboratory parameters in patients where radiological tests were insufficient to clarify the diagnosis. In this cross-sectional and retrospective study, the patients were divided into two groups as PA and AA. Age, sex, length of hospital stay, leukocytes, neutrophil, lymphocyte, CRP, and CLR were recorded at the time of diagnosis. Regression analyses were performed for the parameters, which were found to be statistically significant in univariate analysis. One hundred thirty-one patients were included in this study (111 patients in the AA group, and 20 patients in the PA group). Age (p=0.03), gender (p<0.001), length of hospital stay (p<0.001), CRP (p<0.001), NLR (p=0.004) and CLR (p<0.001) were significantly different between both groups. However, only CLR was found as a significant risk factor in PA cases (p=0.016). The ROC analysis showed the highest AUC value in CLR (0.83). The cut-off value for predicting PA was found 0.45. This study provided that the CLR is an important parameter for the differentiation of AA and PA patients. Besides, it is a valuable predictor in the preoperative risk classification of these patients.

The diagnostic value of ischaemia-modified albumin in acute abdominal pain.

The differential diagnosis of paediatric patients admitted to the emergency department presenting with acute abdominal pain may be difficult. This study aims to investigate the diagnostic value of ischaemia-modified albumin (IMA) in the differential diagnosis of acute abdominal pain in children and in distinguishing surgical from non-surgical cases. The study was conducted with a total of 152 subjects who provided informed consent, including 112 patients admitted to the paediatric emergency department and paediatric surgical clinic and 40 healthy control subjects. Blood samples were collected after initial examination to determine IMA, white blood cell (WBC) and C-reactive protein (CRP) values. Mean IMA values of patients with acute appendicitis (AA), perforated appendicitis (PA) and non-specific abdominal pain were significantly higher compared to the control group. Mean IMA values of the AA and PA cases were also significantly higher compared to the group with non-specific abdominal pain. No significant difference was determined in mean IMA between the AA and PA groups. WBC and CRP levels of the AA and PA groups were significantly higher compared to the group with non-specific abdominal pain. Our study shows that IMA, together with WBC and CRP, may be a biomarker capable of assisting the differential diagnosis of acute abdominal pain in children and distinguishing surgical from non-surgical cases.

72 h Is the Time Critical Point to Operate in Acute Appendicitis

Background and AimsDelay of operative management of acute appendicitis may adversely affect post-operative outcomes and increase the likelihood of post-operative complications occurring. We aim to correlate the duration of symptoms with intra-operative findings to create a timeline of the pathological change in appendicitis. MethodsAppendicectomies performed at a large teaching hospital between June 2015 and July 2016 were prospectively analysed. Time of onset of pain, operative findings, pre-operative C-reactive protein (CRP) and white cell count (WCC) were recorded. Intra-operative findings were categorised by the macroscopic appearance of the appendix, which was subdivided into erythematous, purulent, necrotic and perforated. These results were correlated with the symptom duration. Statistical analysis was completed using Mann-Whitney U and Chi-squared tests. ResultsOne hundred and ninety patients had histologically confirmed appendicitis during the study period. Median time to operation from symptom onset was 49 h. Median time for the appearances of erythematous, purulent, necrotic and perforated appendicitis to develop was 36.5, 41, 55.5 and 86 h, respectively (p value < 0.0001). Median CRP of the non-perforated and perforated appendicitis groups was 22 and 161 mg/L, respectively (p value < 0.0001). Our data demonstrated that after 72 h of symptoms, the likelihood of a perforated appendicitis increased significantly (p value < 0.0001) when compared to 60–72 h. ConclusionsA significant increase in the likelihood of a perforated appendicitis occurs after 72 h of symptoms, when compared to 60–72 h. We can therefore argue that it may be reasonable to prioritise patients approaching 72 h of symptoms for operative management.

Delta neutrophil index: A reliable marker to differentiate perforated appendicitis from non-perforated appendicitis in the elderly.

Delta neutrophil index (DNI) is a new inflammatory marker and the present study aimed to evaluate the predictive value of the DNI for the presence of a perforation in elderly with acute appendicitis. This retrospective observational study was conducted on 108 consecutive elderly patients (≥65years old) with acute appendicitis treated over a 24-month period. Sixty-nine of the 108 patients (median, IQR: 72, 67-77years) were allocated to the perforated appendicitis group (63.9%) and 39 to the non-perforated appendicitis group (36.1%). WBC, neutrophil-to-lymphocyte ratio, platelet-to-lymphocyte ratio and DNI were significantly higher in the perforated group. In multiple logistic regression analyses, initial DNI was the only independent marker that can significantly predict the presence of perforation in multiple regression [odds ratio 9.38, 95% confidence interval (2.51-35.00), P=.001]. Receiver operator characteristic curve analysis showed that DNI is a good predictor for the presence of appendiceal perforation at an optimal cut-off for DNI being 1.4% (sensitivity 67.7%, specificity 90.0%, AUC 0.807). Clinicians can reliably differentiate acute perforated appendicitis from non-perforated appendicitis by DNI level of 1.4 or more in elderly patients.

Feasibility of Single Port Laparoscopic Surgery in Patients with Perforated Appendicitis

Purpose: In recent years, single-port laparoscopic appendectomy (SPLA) has been gaining in popularity and there have been many reports on the results of SPLA. The purpose of this study is to investigate feasibility, safety, and cosmetic satisfaction with SPLA in treatment of perforated appendicitis. Methods: From September 2012 to March 2015, 227 patients underwent SPLA at Damsoyu hospital. The patients were divided into the simple and gangrenous appendicitis group (the S & G group) and the perforated appendicitis group (the P group). Operation time, hospital stay, drain insertion rate, surgical complication, and cosmetic satisfaction were evaluated. Results: A total of 227 patients consisted of 32 patients in the P group and 195 patients in the S & G group. There were no significant differences in the demographic data of the patients. The operation time and hospital stay were significantly longer in the P group (p=0.002 and p Conclusion: SPLA for perforated appendicitis is a feasible, safe, and cosmetically acceptable procedure. However, longer operation time and hospital stay and higher drain insertion rate should be considered for patients undergoing SPLA for perforated appendicitis.

Diagnostic value of red blood cell distribution width in pediatric acute appendicitis.

The aim of this study was to evaluate the diagnostic value of red blood cell distribution width (RDW) in children with acute appendicitis. In this retrospective study, a total of 344 children aged ≤18 years with clinically suspected acute appendicitis who underwent appendectomy between January 2007 and January 2014 were reviewed, and 200 healthy controls of the same age group were included. Based on histopathology, the patients were classified as having normal appendix, simple or perforated appendicitis, and preoperative white blood cell count (WBC), C-reactive protein (CRP) and RDW were compared. Compared with the controls, mean WBC, CRP and RDW were significantly higher in the appendectomy group (P <0.001). The children with simple or perforated appendicitis had significantly higher WBC, CRP and RDW than did those with normal appendix (P <0.001). Mean WBC and CRP were significantly higher in the children with perforated appendicitis (P <0.001), but no statistically significant difference was found in RDW between the simple and perforated appendicitis groups (P = 0.081). Children with histologically proven acute appendicitis have higher RDW than children without appendicitis, but the diagnostic value of RDW was not superior to WBC or CRP in children with acute appendicitis. Although higher RDW may be valuable for aiding the diagnosis of acute appendicitis in children, it is not a useful marker for predicting perforated appendicitis.

Inclusion of C-Reactive Protein and White Blood Cell Count in Diagnostic Workup of Patients with Clinically Suspected Appendicitis Stratifies for Imaging

Objectives: The aim of this retrospective study was to clarify whether plasma markers that are routinely used in the workup of patients suspected for acute appendicitis (AA) can stratify for imaging in both adults and children. Methods: A total of 1388 patients suspected of AA between January 2008 and till 2012 were included. CRP and WBC concentrations were retrospectively abstracted from the electronic health record. Receiver operating characteristic (ROC) curves were used to assess the diagnostic accuracy for the tests and to determine the best cutoff points. Results: In total 432 (22.4%) patients had histopathologically proven AA of whom 45 patients (10.4%) had perforated appendictis. The area under the curve (AUC 95% confidence interval [CI]) was 0.74 (95% CI = 0.70 to 0.77) for CRP and 0.74 (95% Cl = 0.71 to 0.78) for WBC both in adults and children. No cut off points had high enough sensitivity and specificity to accurately diagnose (perforated) AA. However, a high sensitivity of 91% was shown at cut-off 7.5x109/L WBC for AA (both in adults and children). In total 244 (18%) had a cut-off < 7.5×109/L. Those patients could have been sent home. Only 21 (5%) patients would have been missed in the AA group and 1(0.5%) patient in the perforated appendicitis group. Conclusions: None had clinical relevant cutoff points that could accurately discriminate between AA and other pathology, neither perforated appendicitis. However, WBC < 7.5×109/L for AA can identify a subgroup of 245 out of 1388 (18%) patients that could have been sent home without further imaging.

Utility of immature granulocyte percentage in pediatric appendicitis

BackgroundAcute appendicitis is the most common cause of abdominal surgery in children. Adjuncts are used to help clinicians predict acute or perforated appendicitis, which may affect treatment decisions. Automated hematologic analyzers can perform more accurate automated differentials including immature granulocyte percentages (IG%). Elevated IG% has demonstrated improved accuracy for predicting sepsis in the neonatal population than traditional immature-to-total neutrophil count ratios. We intended to assess the additional discriminatory ability of IG% to traditionally assessed parameters in the differentiation between acute and perforated appendicitis. Materials and methodsWe identified all patients with appendicitis from July 2012–June 2013 by International Classification of Diseases-9 code. Charts were reviewed for relevant demographic, clinical, and outcome data, which were compared between acute and perforated appendicitis groups using Fisher exact and t-tests for categorical and continuous variables, respectively. We used an adjusted logistic regression model using clinical laboratory values to predict the odds of perforated appendicitis. ResultsA total of 251 patients were included in the analysis. Those with perforated appendicitis had a higher white blood cell count (P = 0.0063), C-reactive protein (CRP) (P < 0.0001), and IG% (P = 0.0299). In the adjusted model, only elevated CRP (odds ratio 3.46, 95% confidence interval 1.40–8.54) and presence of left shift (odds ratio 2.66, 95% confidence interval 1.09–6.46) were significant predictors of perforated appendicitis. The c-statistic of the final model was 0.70, suggesting fair discriminatory ability in predicting perforated appendicitis. ConclusionsIG% did not provide any additional benefit to elevated CRP and presence of left shift in the differentiation between acute and perforated appendicitis.

Differentiation of early perforated from nonperforated appendicitis: MDCT findings, MDCT diagnostic performance, and clinical outcome

To determine the CT findings and assess their diagnostic performance in differentiating early perforated appendicitis from nonperforated appendicitis, and to compare therapeutic approaches and clinical outcomes between two types of appendicitis. Our retrospective study was approved by our institutional review board and informed consent was waived. From July 2012 to July 2013, 339 patients [mean age 40.8 years; age range 19-80 years; 183 male (mean age 40.5 years; age range 19-79 years) and 156 female (mean age 41.2 years; age range 19-80 years)] who underwent appendectomy with preoperative CT examination for suspected acute appendicitis were included, with exclusion of 37 patients with specific CT findings for advanced perforated appendicitis. And they were categorized into nonperforated and early perforated appendicitis groups according to surgical and pathologic reports. The following CT findings were evaluated by two radiologists blinded to pathologic and surgical findings: transverse diameter of the appendix, thickness of the appendiceal wall, the depth of intraluminal appendiceal fluid, appendiceal wall enhancement, presence or absence of focal defect in the appendiceal wall, intraluminal appendiceal air, appendicolith/fecalith, periappendiceal changes, cecal wall thickening, and free fluid. The type of surgical procedures, performance of surgical drainage, and the length of hospital stay were recorded. Univariate and multivariate logistic regression analysis were used to determine the CT findings for differentiating early perforated appendicitis from nonperforated appendicitis, a total of 75 (22%) of the 339 patients was diagnosed with early perforated appendicitis. Focal wall defect [adjusted odds ratio (aOR), 23.40; p < 0.001], circumferential periappendiceal changes (aOR, 5.63; p < 0.001), appendicoliths/fecaliths (aOR, 2.47; p = 0.015), and transverse diameter of the appendix (aOR, 1.22; p = 0.003) were independently differentiating variables for early perforated appendicitis. The transverse diameter of the appendix (≥11 mm) had the highest sensitivity (62.7%) and focal wall defect in the appendiceal wall showed the highest specificity (98.8%). The prevalence of surgical drainage was higher (p = 0.001) and the mean hospital stay was approximately one day longer (p < 0.001) in the early perforated group than nonperforated group. CT can be helpful in differentiating early perforated appendicitis from nonperforated appendicitis, although the sensitivity of the evaluated findings was somewhat limited.