Evaluation of the appendicitis inflammatory response score for patients with acute appendicitis

Swedish national guidelines for diagnosis and management of acute appendicitis in adults and children

BACKGROUND

Acute appendicitis is one of the most common causes of acute abdominal pain. Differences in the management of this large group of patients has important consequences for the patients and the healthcare system. Controversies regarding the understanding of the natural course of the disease, the utility of new diagnostic methods, and alternative treatments have lead to large variations in practice patterns between centres. These national guidelines present evidence-based recommendations aiming at a uniform, safe and cost-efficient management of this large group of patients.

METHOD

A working group of six experts with broad clinical and research experience was formed. Additional expertise from outside was consulted during the process. A national survey revealed significant variations in the management of patients with suspicion of appendicitis. The evidence provided in published guidelines and reviews were extracted and systematically graded, according to the GRADE methodology. This was supplemented by additional more recent and more directed search of the literature. Patients treated for appendicitis were involved through interviews. The guidelines were reviewed by external experts before the final version was determined.

RESULTS

The guidelines cover an extensive number of issues: pathology, epidemiology, aetiology, natural history, clinical and laboratory diagnosis, diagnostic scoring systems, diagnostic imaging, treatment, nursing care, follow-up, quality registers and quality indicators, among others. Special considerations related to children and pregnant women are covered.

CONCLUSION

These national guidelines present an extensive and thorough review of the current knowledge base related to appendicitis, and provide up-to-date evidence-based recommendations for the management of this large group of patients.

Diagnostic value of the appendicitis inflammatory response (AIR) score. A systematic review and meta-analysis

BACKGROUND

Clinical scoring algorithms are cost efficient in patients with suspicion of acute appendicitis. This is a systematic review and meta-analysis of the diagnostic properties of the Appendicitis Inflammatory Response (AIR) score compared with the Alvarado score.

METHODS

The PubMed, EMBASE, Web of Science and Google Scholar databases were searched for reports on the diagnostic properties of the AIR score from 2008 to July 18, 2024. A meta-analysis of the receiver operating characteristic (ROC) area and the sensitivity and specificity for all and advanced appendicitis patients was performed. Advanced appendicitis was defined as perforated or gangrenous appendicitis or appendicitis abscess or phlegmon or if described as complicated appendicitis. The risk of bias was estimated via the QUADAS-2 tool. The ROC areas of the AIR score and the Alvarado score were compared.

RESULTS

A total of 26 reports with a total of 15.699 patients were included. The area under the ROC curve for the AIR score was 0.86 (95% CI 0.83-0.88) for all patients with appendicitis and 0.93 (CI 0.91-0.96) for those with advanced appendicitis, which was greater than the corresponding areas for the Alvarado score (0.79, CI 0.76; 0.81) and 0.88, CI 0.82; 0.95), respectively. At > 4 points, the sensitivity was 0.91 (CI 0.88; 0.94) for all patients with appendicitis and 0.95 (CI 0.94; 0.97) for those with advanced appendicitis. At > 3 points, the sensitivity was 0.95 (0.90; 0.97) for all patients with appendicitis and 0.99 (0.97; 0.99) for those with advanced appendicitis. At > 8 points, the specificity was 0.98 (0.97; 0.99) for all patients with appendicitis and 0.99 (0.97; 0.99) for those with advanced appendicitis. The included studies had a low risk for bias and low heterogeneity.

CONCLUSION

The AIR score has a better diagnostic capacity than the Alvarado score does. The AIR score is a safe and efficient basis for risk-stratified management of patients suspected of having appendicitis.

Nomogram prediction model for length of hospital stay following laparoscopic appendectomy in pediatric patients: a retrospective study

Objective

The aim of this research was to develop and internally validate a nomogram for forecasting the length of hospital stay following laparoscopic appendectomy in pediatric patients diagnosed with appendicitis.

Methods

We developed a prediction model based on a training dataset of 415 pediatric patients with appendicitis, and hospitalization data were collected retrospectively from January 2021 and December 2022. The primary outcome measure in this study was hospital length of stay (LOS), with prolonged LOS defined as admission for a duration equal to or exceeding the 75th percentile of LOS, including the discharge day. Risk factor analysis was conducted through univariate and multivariate logistic regression analyses. Based on the regression coefficients, a nomogram prediction model was developed. The discriminative performance of the predicting model was evaluated using the C-index, and an adjusted C-index was computed through bootstrapping validation. Calibration curves were generated to assess the accuracy of the nomogram. Decision curve analysis was conducted to determine the clinical utility of the predicting model.

Results

Predictors contained in the prediction nomogram included Age, neutrophil-to-lymphocyte ratio, C-reactive protein level, operative time, appendiceal fecalith, and drainage tube. The C-index of the prediction nomogram was determined to be 0.873 (95% CI: 0.838-0.908), with a corrected C-index of 0.8625 obtained through bootstrapping validation (1,000 resamples), indicating the model's favorable discrimination. Calibration curves illustrated a strong agreement between predicted and observed outcomes. According to the decision curve analysis of the nomogram, the predictive model demonstrates a net benefit at threshold probabilities exceeding 2%.

Conclusion

This nomogram, incorporating variables such as Age, neutrophil-to-lymphocyte ratio, C-reactive protein level, operative time, appendiceal fecalith, and drainage tube, offers a convenient method for assessing the duration of hospitalization in pediatric patients with appendicitis.

Non-linear association between C-reactive protein levels and length of stay in pediatric appendicitis patients undergoing laparoscopic appendectomy

Objective

To examine the correlation between C-reactive protein (CRP) levels at hospital admission and the length of stay (LOS) in pediatric patients with appendicitis who underwent laparoscopic appendectomy.

Methods

We retrospectively collected the clinical data from pediatric patients diagnosed with acute appendicitis and treated with laparoscopic appendectomy. Multivariate generalized linear regression analyses were performed to determine the independent relationship between CRP and LOS. Smooth curve fitting was constructed to examine the potential non-linear relationship between CRP and LOS. A segmented regression model was used to calculate threshold effects and determine the inflection point.

Results

A total of 815 participants were included in the study. Multiple linear regression analysis indicated that the higher the CRP levels, the longer the LOS. Fully adjusted smooth curve fitting suggested a non-linear relationship between CRP and LOS. A segmented regression showed that the inflection point value of CRP was 34.13 mg/L. A 1 mg/L increase in CRP levels was significantly associated with a 0.013-day increase in length of stay (95% CI: 0.009, 0.018; P < 0.001) when CRP levels > 34.13 mg/L. However, there was no significant association between CRP and LOS when CRP levels < 34.13 mg/L (P > 0.05).

Conclusion

There was a non-linear association and threshold effect between CRP levels and LOS. CRP levels above 34.13 mg/L were associated with longer LOS in pediatric appendicitis patients. These findings contribute to the understanding of inflammatory markers in recovery dynamics and underscore the necessity for further research to investigate their potential clinical implications.

Novel Ultrasonographic Evaluation of Microvascular Blood Flow for Non-Operative Management of Uncomplicated Acute Appendicitis in Children: A Prospective Clinical Study

OBJECTIVES

To determine whether superb microvascular imaging (SMI) provides a more precise delineation between reversible and irreversible stages of uncomplicated acute appendicitis managed non-operatively.

METHODS

This prospective clinical study examined pediatric patients with acute appendicitis initially treated non-operatively and evaluated using power Doppler (PD) and SMI. We determined case severity, monitor appendiceal blood flow (BF), and appendicitis reversibility. Complicated cases were excluded. Severity was classified using B-mode as well as PD, or SMI: Grade I, smooth wall/normal BF; Grade IIa, irregular wall/increased BF; Grade IIb, irregular wall/decreased BF; and Grade III, absence of wall/loss of BF.

RESULTS

This study examined a total of 100 patients with acute appendicitis, after excluding 29 patients. All 10 patients with normal BF on PD (Grade I) showed similar BF on SMI (Grade I). Among 29 patients with increased BF on PD (Grade IIa), corresponding increased BF was noted on SMI (Grade IIa), and all these patients showed full recovery. Of the 55 patients showing decreased BF on PD (Grade IIb), 52 showed increased BF on SMI (Grade IIa). The remaining three patients, identified with an impacted appendicolith, showed decreased BF on SMI (Grade IIb) and experienced treatment failure, subsequently developing abscesses. In all six patients with undetectable BF on PD (Grade III), SMI similarly could not detect appendiceal BF (Grade III), and non-operative management failed for these patients.

CONCLUSIONS

SMI offers an objective and effective means of delineating the threshold between reversible and irreversible stages in uncomplicated acute appendicitis following non-operative management.

Inflammatory Signals Across the Spectrum: A Detailed Exploration of Acute Appendicitis Stages According to EAES 2015 Guidelines

Background: In this retrospective study, we evaluate the diagnostic utility of C-reactive protein (CRP) and leucocyte count within the EAES 2015 guidelines for acute appendicitis (AA) in differentiating uncomplicated (UAA) from complicated AA (CAA). Methods: Conducted at a tertiary care center in Germany, the study included 285 patients over 18 years who were diagnosed with AA from January 2019 to December 2021. Patient data included demographics, inflammatory markers, and postoperative outcomes. Results: CRP levels (Md: 60.2 mg/dL vs. 10.5 mg/dL; p < 0.001) and leucocyte count (Md: 14.4 Gpt/L vs. 13.1 Gpt/L; p = 0.016) were higher in CAA. CRP had a medium diagnostic value for detecting CAA (AUC = 0.79), with a cutoff at 44.3 mg/L, making it more likely to develop CAA. Leucocyte count showed low predictive value for CAA (AUC = 0.59). CRP ≥ 44.3 mg/L was associated with a higher risk of postoperative complications (OR: 2.9; p = 0.002) and prolonged hospitalization (OR: 3.5; p < 0.001). Conclusions: CRP, within the context of the EAES classification, presents as a valuable diagnostic marker to distinguish CAA from UAA, with a higher risk of postoperative complications and hospitalization. Leucocyte count showed low diagnostic value for the identification of CAA.

Blood biomarkers to distinguish complicated and uncomplicated appendicitis in pediatric patients

BACKGROUND/PURPOSE

Acute appendicitis (AA) stands as the most prevalent cause of acute abdominal pain among children. The potential for morbidity escalates significantly when uncomplicated appendicitis (UA) progresses to complicated appendicitis (CA), which can encompass gangrenous, necrotic, or perforated appendicitis. Consequently, establishing an early and accurate diagnosis of AA, and effectively differentiating CA from UA, becomes paramount. This study explores the diagnostic utility of various blood biomarkers for distinguishing CA from UA in pediatric patients.

METHODS

We conducted a retrospective review of medical records pertaining to pediatric patients who underwent surgery for AA. Patients were categorized as either having UA or CA based on histopathological examination of the appendix. The data collected and analyzed included demographic information, white blood cell (WBC) count, neutrophil proportion, lymphocyte proportion, neutrophil-to-lymphocyte ratio (NLR), monocyte-to-lymphocyte ratio (MLR), platelet-to-lymphocyte ratio (PLR), and C-reactive protein (CRP) levels upon admission.

RESULTS

Among the 192 pediatric patients who underwent surgery for AA, 150 were diagnosed with UA, while 42 were diagnosed with CA. The CA group exhibited significantly higher neutrophil proportions, NLRs, PLRs, and CRP levels, alongside lower lymphocyte proportions (all p < 0.01) compared to the UA group. Receiver operating characteristic (ROC) curve analysis disclosed that CRP exhibited the highest specificity, sensitivity, and positive and negative predictive values for predicting CA.

CONCLUSION

CRP emerges as a valuable biomarker for differentiating complicated appendicitis from uncomplicated appendicitis.

Current use of artificial intelligence in the diagnosis and management of acute appendicitis

INTRODUCTION

Acute appendicitis is a common and time-sensitive surgical emergency, requiring rapid and accurate diagnosis and management to prevent complications. Artificial intelligence (AI) has emerged as a transformative tool in healthcare, offering significant potential to improve the diagnosis and management of acute appendicitis. This review provides an overview of the evolving role of AI in the diagnosis and management of acute appendicitis, highlighting its benefits, challenges, and future perspectives.

EVIDENCE ACQUISITION

We performed a literature search on articles published from 2018 to September 2023. We included only original articles.

EVIDENCE SYNTHESIS

Overall, 121 studies were examined. We included 32 studies: 23 studies addressed the diagnosis, five the differentiation between complicated and uncomplicated appendicitis, and 4 studies the management of acute appendicitis.

CONCLUSIONS

AI is poised to revolutionize the diagnosis and management of acute appendicitis by improving accuracy, speed and consistency. It could potentially reduce healthcare costs. As AI technologies continue to evolve, further research and collaboration are needed to fully realize their potential in the diagnosis and management of acute appendicitis.

Referrals for Pediatric Appendicitis to a Tertiary Care Children's Hospital

OBJECTIVES

This study aimed to analyze pediatric referrals for definite or possible appendicitis, to compare clinical predictors and laboratory values between patients with and without a final diagnosis of appendicitis, and to determine the accuracy of prereferral diagnostic interpretations of computed tomography scans, ultrasound, and magnetic resonance imaging modalities.

METHODS

We conducted a retrospective analysis of pediatric patients referred from 2015 to 2019 to a tertiary care children's emergency department with definitive or possible appendicitis. Data abstracted included patient demographics, clinical symptoms, physical examination findings, laboratory results, and diagnostic imaging findings (by the referring center and the pediatric radiologist at the accepting center). An Alvarado and Appendicitis Inflammatory Response (AIR) score was calculated for each patient.

RESULTS

Analysis was performed on 381 patients; 226 (59%) had a final diagnosis of appendicitis. Patients with appendicitis were more likely to have symptoms of nausea ( P < 0.0001) and vomiting ( P < 0.0001), have a higher mean temperature ( P = 0.025), right lower quadrant abdominal pain to palpation ( P = <0.0001), rebound tenderness ( P < 0.0001), a higher mean Alvarado score [5.35 vs 3.45 ( P < 0.0001)], and a higher mean AIR score [4.02 vs 2.17 ( P < 0.0001)]. Of the 97 diagnostic images initially interpreted as appendicitis by the referring center, 10 (10.3%) were read as no evidence of appendicitis. Of the 62 diagnostic images initially interpreted as "possible appendicitis" by the referring center, 34 (54.8%) were read as no evidence of appendicitis. Of those diagnostic images initially interpreted as "appendicitis" or "possible appendicitis" by the referring center, 24/89 (27.0%) of computed tomography scans, 17/62 (27.4%) of ultrasounds, and 3/8 (37.5%) of magnetic resonance imaging results were read as no evidence of appendicitis.

CONCLUSIONS

Usage of established scoring algorithms, such as Alvarado and AIR, may decrease the unnecessary cost of diagnostic imaging and transfer to tertiary care. Virtual radiology consultations may be 1 potential solution to improve the referral process for pediatric appendicitis if initial interpretation is uncertain.

Performance and diagnostic accuracy of scoring systems in adult patients with suspected appendicitis

BACKGROUND

This study aims to determine the most accurate appendicitis scoring system and optimal cut-off points for each scoring system.

METHODS

This single-centred prospective cohort study was conducted from January-to-June 2021, involving all patients admitted on suspicion of appendicitis. All patients were scored according to the Alvarado score, Appendicitis Inflammatory Response (AIR) score, Raja Isteri Pengiran Anak Saleha (RIPASA) score and Adult Appendicitis score (AAS). The final diagnosis for each patient was recorded. Sensitivity and specificity were calculated for each system. Receiver operating characteristic (ROC) curve was constructed for each scoring system, and the area under the curve (AUC) was calculated. Optimal cut-off scores were calculated using Youden's Index.

RESULTS

A total of 245 patients were recruited with 198 (80.8%) patients underwent surgery. RIPASA score had higher sensitivity and specificity than other scoring systems without being statistically significant (sensitivity 72.7%, specificity 62.3%, optimal score 8.5, AUC 0.724), followed by the AAS (sensitivity 60.2%, specificity 75.4%, optimal score 14, AUC 0.719), AIR score (sensitivity 76.7%, specificity 52.2%, optimal score 5, AUC 0.688) and Alvarado score (sensitivity 69.9%, specificity 62.3%, optimal score 5, AUC 0.681). Multiple logistic regression revealed anorexia (p-value 0.018), right iliac fossa tenderness (p-value 0.005) and guarding (p-value 0.047) as significant clinical factors independently associated with appendicitis.

CONCLUSION

Appendicitis scoring systems have shown moderate sensitivity and specificity in our population. The RIPASA scoring system has shown to be the most sensitive, specific and easy-to-use scoring system in the Malaysian population whereas the AAS is most accurate in excluding low-risk patients.

Does one of the two most commonly used scoring systems have a decisive advantage over the other in diagnosing acute appendicitis in pregnant women?

This study aimed to compare the accuracy and reliability of Alvarado Score (AS) and Appendicitis Inflammatory Response Score (AIRS) in pregnant women undergoing surgery for acute appendicitis (AA). The files of 53 pregnant women with a diagnosis of AA who underwent surgery in our clinic between February 2014 and December 2018 were examined retrospectively. The patients were divided into 3 groups as follows: first trimester between 0 and 14 weeks, second trimester between 15 and 28 weeks, and third trimester between 29 and 42 weeks. The AS and AIRS values were calculated according to preoperative physical examination and laboratory results. The mean age of the patients was 28.58 (18-44) years. According to the pathology results, appendicitis was detected in 16 of 23 patients in the first trimester, in 22 of 25 patients in the second trimester, and in 2 of 5 patients in the third trimester. The AIRS was ≥ 9 in 9 patients and the AS was ≥ 7 in 19 of the 23 patients in the 1st trimester, while the AIRS was ≥ 9 in 11 patients and the AS was ≥ 7 in 19 of the 25 patients in the 2nd trimester. However, in the 3rd trimester, the AIRS was ≥ 9 in 2 patients and AS was ≥ 7 in 4 of the 5 patients. In conclusion, when the data obtained from the present study were evaluated, it was determined that both AS and AIRS are effective methods for diagnosing AA in pregnant women.

Predictive value of immature granulocyte in the diagnosis of acute complicated appendicitis

INTRODUCTION

The goal in appendicitis is early diagnosis and early treatment. Complications develop as treatment is delayed. Therefore, there is a need for fast, low-cost markers that can be diagnosed earlier. The aim of this study is to show the effectiveness of immature granulocyte (IG) level in determining the complication of acute appendicitis.

METHOD

In this retrospective cross-sectional study, 99 patients with acute appendicitis and 41 control groups were included in the study. Acute appendicitis patients were divided into two groups as acute simple appendicitis(n = 65) and acute complicated appendicitis(n = 34). In all groups, demographic data, immature granulocyte (IG) count(x103/μL), IG ratio (IG%), white blood cell (WBC), polymorphonuclear leukocytes (PNL), lymphocyte, monocyte, platelet, mean platelet volume (MPV), ferritin levels were recorded. The blood analyses were performed the Mindray BC6800 automated hematology analyzer using standard laboratory protocols. All statistical testing was undertaken using IBM SPSS Statistics for Mac.

RESULTS

Compared to the acute simple appendicitis, acute complicated appendicitis patients had significantly higher levels WBC, PNL, monocyte, IG count, and IG% (p = 0.009, p = 0047, p = 0.001, p = 0.018; respectively) while there was no significant difference in ferritin between groups (p = 0.49). In the ROC analysis, AUC value was found for IG count and IG% (0.893 and 0.725, cut-off 0.005 and 0.05; respectively) for acute appendicitis. The negative predictive value of IG for Acute Appendicitis was 85% and was the same as that of WBC. In acute complicated appendicitis, the AUC for IG and IG% was 0.796 (cut-off 0.02) and 0.693 (cut-off 0.2), respectively. Positive Likelihood Ratio (+LR; 2.1) value of IG was found higher than other complete blood count (CBC) tests.

CONCLUSION

The IG count is test with fast, more predictive value than another CBC tests, and without cost in the early diagnosis of acute complicated appendicitis. It is strong negative predictive test for Acute Appendicitis disease.

Applicability of American College of Radiology Appropriateness Criteria Decision-Making Model for Acute Appendicitis Diagnosis in Children

Acute appendicitis is one of the most common causes of abdominal pain in the emergency department and the most common surgical emergency reason for children younger than 15 years of age, which could be enormously dangerous when ruptured. The choice of radiological approach is very important for the diagnosis. In this way, unnecessary surgery is avoided. The aim of this study was to examine the validity of the American College of Radiology appropriateness criteria for radiological imaging in diagnosing acute appendicitis with multivariate decision criteria. In our study, pediatric patients who presented to the emergency department with abdominal pain were grouped according to the Appendicitis Inflammatory Response (AIR) score and the choice of radiological examinations was evaluated with fuzzy-based Preference Ranking Organization Method for Enrichment Evaluation (PROMETHEE) and with the fuzzy-based Technique for Order of Preference by Similarity to Ideal Solution (TOPSIS) model for the validation of the results. As a result of this study, non-contrast computed tomography (CT) was recommended as the first choice for patients with low AIR score (where Φnet=0.0733) and with high AIR scores (where Φnet=0.0702) while ultrasound (US) examination was ranked third in patients with high scores. While computed tomography is at the forefront with many criteria used in the study, it is still a remarkable practice that US examination is in the first place in daily routine. Even though there are studies showing the strengths of these tools, this study is unique in that it provides analytical ranking results for this complex decision-making issue and shows the strengths and weaknesses of each alternative for different scenarios, even considering vague information for the acute appendicitis diagnosis in children for different scenarios.

Optimising the treatment for uncomplicated acute appendicitis (OPTIMA trial): a protocol for a multicentre, randomised, double-blinded placebo-controlled study

INTRODUCTION

Emerging evidence has shown that an antibiotic first strategy is a viable treatment option for uncomplicated acute appendicitis (AA). Although there has recently been an interest and increase in the use of antibiotics as the primary strategy for treating uncomplicated AA, there is no consensus regarding the optimum antibiotic regimen. In particular, the long-term outcomes of different antibiotic regimens, such as the recurrence rate, still lack evidence. Given that the flora of the appendix is mainly anaerobic bacteria, we hypothesised that antianaerobe regimens could decrease the recurrence rate compared with those that did not include antianaerobic antibiotics.

METHODS AND ANALYSIS

The OPTIMA(Optimising the treatment for uncomplicated acute appendicitis) trial is a multicentre, double-blinded placebo-controlled superiority randomised study aimed to evaluate the role of antianaerobic antibiotics in the resolution of uncomplicated AA. Patients (18-65 years) with uncomplicated AA (without gangrenous, perforated appendicitis, appendiceal abscess, or appendiceal fecaliths) are eligible for inclusion. The primary endpoint of this study is the success rate of the treatment, defined as the resolution of AA resulting in discharge from the hospital without surgical intervention and recurrent symptoms within one year. Secondary endpoints include mortality, postintervention complications, recurrent symptoms up to one year after treatment, hospital stay, sick leave, treatment cost, pain symptom scores and quality of life. Data are reported as the number of cases (%), median (range) and relative risk, which will be analysed using the Mann-Whitney U test or χ2 test, as appropriate. P-value<0.05 will be considered significant.

ETHICS AND DISSEMINATION

The protocol has been approved by the Ethics Committee of Jinling Hospital on 13 November 2018 (2018NZKY-027-01). The trial findings will be published in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

ChiCTR1800018896.

Comparison of Appendicitis Inflammatory Response (AIR) and Lintula scoring systems in diagnosing acute appendicitis among children

Appendectomy is still the best treatment for acute appendicitis in pediatric patients. Given the problems of early and immediate diagnosis of acute appendicitis, defining the best diagnostic protocol for this condition is of utmost importance. Different diagnostic methods, such as Lintula and appendicitis inflammatory response (AIR) scoring systems, are used for this purpose. This study aims to compare Lintula and AIR scoring systems among children with suspicion of acute appendicitis regarding their postoperative outcomes. During two years, a prospective multicentric study was carried out in the selected hospitals of Iran. Pediatric patients admitted with the diagnosis of acute appendicitis were enrolled in the study. Before decision making, each patient's score was calculated according to two appendicitis scoring systems of Lintula and AIR. The clinical outcomes and diagnosis of patients were then compared to the results of each scoring system. For those patients who were a candidate to undergo surgery, the final diagnosis of acute appendicitis was made by histopathology. Patients were divided into high and low-risk groups according to scoring systems outcomes. Among the patients with lower scoring for appendicitis, the AIR scoring system had a sensitivity and specificity of 95%, which was more promising than that of the Lintula system (19%); however, the specificity was comparable between the two models (74% vs. 83%). For patients at higher risk of acute appendicitis, although the AIR scoring systems did not provide reliable results (sen: 45% and spe: 25%), the Lintula scoring showed remarkable sensitivity (87%), accompanied by a high diagnostic accuracy (87%). AIR and Lintula scoring systems are not accurate models to predict the risk of acute appendicitis among children; therefore, they can serve as an adjacent modality for other diagnostic methods.

Demographic factors associated with length of stay in hospital and histological diagnosis in adults undergoing appendicectomy

Objective: Appendicectomy remains of the most common emergency operations in the United Kingdom. The exact etiologies of appendicitis remain unclear with only potential causes suggested in the literature. Social deprivation and ethnicity have both been demonstrated to influence outcomes following many operations. There are currently no studies evaluating their roles with regards to severity and outcomes following appendicectomy.

Material and Methods: Demographic data were retrieved from health records for adult patients who underwent appendicectomy between 2010-2016 within a single NHS trust. To measure social deprivation, Indices of Multiple Deprivation (IMD) rankings were used. Histology reports were reviewed and diagnosis classified into predefined categories: non-inflamed appendix, uncomplicated appendicitis, complicated appendicitis and gangrenous appendicitis.

Results: Three thousand four hundred and forty-four patients were identified. Mean age was 37.8 years (range 73 years). Using a generalized linear model, South Asian ethnicity specifically was found to be independently predictive of increased length of stay following appendicectomy (p< 0.001). Amongst South Asian patients, social deprivation was found to be further predictive of longer hospital stay (p= 0.005). Deprivation was found to be a predictor of complicated appendicitis but not of gangrenous appendicitis (p= 0.01). Male gender and age were also independent predictors of positive histology for appendicitis (p< 0.001 and p= 0.021 respectively).

Conclusion: This study is the first to report an independent association between South Asian ethnicity and increased length of stay for patients undergoing appendicectomy in a single NHS trust. The associations reported in this study may be a result of differences in the pathophysiology of acute appendicitis or represent inequalities in healthcare provision across ethnic and socioeconomic groups.

Predictive values of Alvarado score, serum C-reactive protein, and white blood cell count in the diagnosis of acute appendicitis: a prospective study

Background

The diagnosis of acute appendicitis in children is quite challenging as the rate of negative appendectomy varies between 15 and 57%. Increased utilization of imaging diagnostic facilities in advanced countries seems to have reduced the incidence of operating on normal appendix to a single digit. In low- and middle-income countries, the incidence remains unacceptably high (double digits). Inflammatory markers and scoring systems may be a suitable adjunct to increase diagnostic yield in most third world countries. Thus, the aim of this study was to evaluate the diagnostic value of Alvarado score, white blood cell count, and serum C-reactive protein in children with acute appendicitis.

Results

The ages of patients ranged between 4 and 15 years with a mean of 11.2 ± 2.8 years. The male to female ratio was 1.4 to 1.0. Nineteen percent of patients had negative appendiceal findings on histological examination. The sensitivity and specificity of Alvarado score, C-reactive protein estimation, total white blood cell count in diagnosing acute appendicitis were 86.4% and 63.2%, 98.8% and 36.8%, and 51.9% and 89.5% respectively. Alvarado score has the highest area under ROC curve analysis 0.824, 95% CI of 0.724 to 0.924 compared with CRP, 0.769. 95% CI of = 0.647 to 0.891 and WBC count, 0.765, 95% CI of 0.643 to 0.887. Both CRP and WBC count showed higher discriminatory values between complicated and uncomplicated appendicitis, p < 0.001.

Conclusion

Alvarado score outperformed other tests in setting the diagnosis of acute appendicitis. However, none of the tests can be relied on wholly for operative decision. Clinical judgement remains the bedrock for diagnosis and operative management.

Clinical Decision Rules in the Evaluation and Management of Adult Gastrointestinal Emergencies

Although abdominal pain is a common chief complaint in the emergency department, only 1 in 6 patients with abdominal pain are diagnosed with a gastrointestinal (GI) emergency. These patients often undergo extensive testing as well as hospitalizations to rule out an acute GI emergency and there is evidence that not all patients benefit from such management. Several clinical decision rules (CDRs) have been developed for the diagnosis and management of patients with suspected acute appendicitis and upper GI bleeding to identify those patients who may safely forgo further testing or hospital admission. Further validation studies demonstrating the superiority of these CDRs over contemporary practice are needed.

Sonographic diagnosis of appendicitis: A pictorial essay and a new diagnostic maneuver

While many cases of appendicitis are easy to diagnose clinically, a significant number need further workup in the form of imaging. Ultrasound and CT are both used extensively to diagnose or exclude appendicitis, or arrive at an alternate diagnosis. Ultrasound has many advantages but can be a difficult modality to use due to, among other reasons, the anatomical variations in appendicial location. The true retrocolic appendix is particularly difficult to diagnose with ultrasound. This pictorial essay examines the ultrasound features of normal and diseased appendix and proposes a new examining station, the prone view, for visualizing true retrocolic appendicitis.

Consensus Statement of the Italian Polispecialistic Society of Young Surgeons (SPIGC): Diagnosis and Treatment of Acute Appendicitis

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.

Clinical Significance of Variable Histomorphologic Findings Related to Mucosal Inflammation in Negative Appendectomy

The aim of the study was to investigate the clinical significance of various histomorphologic findings related to mucosal inflammation in negative appendectomy. We reviewed histopathologic findings of 118 negative appendectomies and correlated them with the appendicitis inflammatory response (AIR) score and appendiceal diameter. Among 118 patients with negative appendectomy, 94 (80%), 73 (78%) and 89 (75%) patients displayed mucosal inflammation, high neutrophil score (neutrophil count ≥10/5 high power field and surface epithelial flattening, respectively. Out of 118 patients with negative appendectomy, mucosal inflammation, high neutrophil score and surface epithelial flattening were associated with higher risk group according to the appendicitis inflammatory response (AIR) score (p < 0.05, respectively). In addition, mucosal inflammation, high neutrophil score and surface epithelial flattening were frequently detected in 118 negative appendectomies, compared with 24 incidental appendectomies (p < 0.05, respectively). In an analysis of 77 negative appendectomy patients with appendiceal diameter data available, increased appendiceal diameter was positively correlated with luminal inflammation, high neutrophil score and surface epithelial flattening (p < 0.05, respectively). In conclusion, mucosal inflammation, high neutrophil score and surface epithelial flattening in negative appendectomy may be relevant to patients’ signs and symptoms, especially in cases with no other cause of the abdominal pain.

Appendicitis Inflammatory Response Score in Comparison to Alvarado Score in Acute Appendicitis

Appendicitis is a common differential diagnosis of right lower quadrant pain. Clinical evaluation alone results in high negative appendicectomy rates. Alvarado scoring is the most commonly used clinical prediction rule. The study aimed to compare the recently developed appendicitis inflammatory response (AIR) score with the Alvarado score. This cross-sectional observational study included patients who underwent appendicectomy for clinical suspicion of appendicitis. The clinical and laboratory parameters required for obtaining Alvarado score and AIRS were gathered. Area under ROC curve was calculated for both Alvarado score and AIRS. The study included 130 patients (77 males and 53 females). The negative appendicectomy rate was 10.7%. The perforation rate was 10.3%. The area under ROC for Alvarado score was 0.821 and for AIR score was 0.901. The Alvarado score had a sensitivity of 72% and a specificity of 79% at score ≥6. The appendicitis inflammatory response score had a sensitivity of 98% for scores ≥5 and a specificity of 97% for score ≥6. The C-reactive protein (CRP) value was the best performing individual parameter with an area under ROC of 0.789, followed by WBC count with an area under ROC of 0.762. Appendicitis inflammatory response score is a recently developed score that outperforms the Alvarado score. AIR score has a higher specificity. The sound construction, gradation of parameters, the inclusion of CRP, and avoidance of subjective parameters make the AIR score an attractive clinical prediction rule which can decrease the rate of negative appendicectomy.

Scoring System for Differentiation of Complicated Appendicitis in Pediatric Patients: Appendicitis Scoring System in Children

Although several scoring systems have been used to differentiate simple acute appendicitis from perforated appendicitis, no particular system has been widely accepted. Therefore, this study aimed to investigate preoperative factors associated with complicated appendicitis and to develop a scoring system that distinguishes complicated appendicitis in children aged <10 years. Patients aged <10 years who underwent surgical treatment for acute appendicitis between 2011 and 2019 were included in this study, after excluding those with insufficient medical records, with other diseases that affect the length of hospitalization, or without formal reports of abdominal computed tomography (CT) or ultrasonography (US). Complicated appendicitis was defined as hospitalization for ≥5 days postoperatively or readmission within 30 days postoperatively. Patient characteristics, symptoms, physical examination, laboratory data, and radiographic results were collected to determine predictors of complicated appendicitis. The mean age of 279 patients was 7.3 years. Among them, 57 patients had complicated appendicitis. A scoring system was developed based on the following 5 independent risk factors derived from multiple logistic regression analysis: body temperature, anorexia, diarrhea, C-reactive protein (CRP) level, and presence of periappendiceal free fluid on CT or US. The scoring system resulted in an area under the curve of .898 (P < .001). For patients aged <10 years, a new model that includes objective factors, such as body temperature, CRP levels, and radiography results, might help predict complicated appendicitis and determine treatment plans.

Clinical Prediction Scores for Pediatric Appendicitis

INTRODUCTION

 The rate of misdiagnosis of appendicitis in children is a challenge and clinical prediction scores could be part of the solution. However, the pediatric appendicitis score (PAS) and the Alvarado score have shown disappointing diagnostic accuracy in pediatric validation studies, while the appendicitis inflammatory response (AIR) score and the novel pediatric appendicitis risk calculator (pARC) have not yet been validated thoroughly. Therefore, the aim of the present study was to evaluate these four prediction scores prospectively in children with suspected appendicitis.

MATERIALS AND METHODS

 A prospective study was conducted over a 2-year period. All patients <15 years with suspected appendicitis were eligible for inclusion. The four prediction scores were compared regarding predictive values, receiver operating characteristics (ROC) curves, decision curve analysis, and clinical outcome.

RESULTS

 Of the 318 patients included, 151 (47 %) patients had appendicitis. The AIR score and the pARC had substantially higher specificity and positive predictive value, and lower rate of false positives (7% and 2%), than the PAS and Alvarado score (36 and 28%, p < 0.001). Across the different gender and age groups, the AIR score and the pARC generally had fewer false positives than the PAS and Alvarado score. There were no significant differences in sensitivity, negative predictive values, rates of missed appendicitis, or ROC curve analysis. In decision curve analysis, the AIR score and the pARC outperformed the PAS and Alvarado score at most threshold probabilities.

CONCLUSION

 The AIR score and the pARC are superior to the PAS and Alvarado score in diagnosing children with suspected appendicitis.

Role of platelet indices as a biomarker for the diagnosis of acute appendicitis and as a predictor of complicated appendicitis: A meta-analysis

INTRODUCTION

Acute appendicitis is one of the most common surgical emergencies worldwide. Clinical scoring system systems have been developed to diagnose acute appendicitis, but insufficient to predict the complication. The amount of serum biomarkers elevates in response to acute inflammation, which could be beneficial for diagnostic tools. Accordingly, a meta-analysis was conducted to evaluate the efficacy of platelet indices, including mean platelet volume (MVP) and platelet distribution width (PDW) as potential biomarkers for the diagnosis of a diagnosis of acute appendicitis.

MATERIAL AND METHODS

The dataset was defined by searching for articles published until December 2020 from PubMed, EMBASE, Google Scholar and the Cochrane database. The meta-analysis was performed using Review Manager Software version 5.4.1.

RESULTS

The final analysis was made from 9 studies, including 3124 patients. The results demonstrated that lower MPV values was significantly associated with acute appendicitis (odds ratio (OR) = 0.81, 95% confidence interval (CI) = -1.51 to -0.11, P = 0.02), but not associated with complicated appendicitis by comparing it with the control (OR = -0.13,95% CI = -0.33 to -0.07, P = 0.19) and non-complicated appendicitis groups (OR = -0.13,95% CI = -0.30 to -0.04, P = 0.14). The present study failed to demonstrate the diagnostic value of PDW for the prediction of appendicitis and its complication.

CONCLUSION

The results of the meta-analysis strongly indicate that a lower MVP values could function as a marker for predicting the acute appendicitis.

Validity of Appendicitis Inflammatory Response Score in Distinguishing Perforated from Non-Perforated Appendicitis in Children

Background: This prospective observational study aimed to evaluate the validity of appendicitis inflammatory response (AIR) score in differentiating advanced (perforated) from simple (non-perforated) appendicitis in pediatric patients. Methods: A single-center prospective cross-sectional study was conducted between 1 January 2019 until 1 May 2020 including 184 pediatric patients who underwent appendectomy. Based on the intraoperative finding of advanced (n = 38) or simple (n = 146) appendicitis the patients were divided into two groups. Recipient-operator curve (ROC), with calculation of sensitivity and specificity of best cutoff and the area under the curve (AUC), were used to measure the diagnostic value and the potential for risk stratification of the AIR score, among the patients with simple or advanced acute appendicitis. Results: The median value of the AIR score in the perforated and non-perforated groups was 10 (interquartile range, IQR 9, 11), and was 7 (IQR 6, 9), respectively (p < 0.001). Based on the calculated value of AIR score, the patients were classified with a high precision into low, indeterminate and high risk groups for acute appendicitis (p < 0.001). A cutoff value of ≥9 was demonstrated to serve as a reliable indicator of perforated appendicitis with a sensitivity and a specificity of 89.5% and 71.9%, respectively (AUC = 0.80; 95% CI: 0.719–0.871; p < 0.001). Conclusions: Acute appendicitis can be detected with a high level of sensitivity and specificity using the AIR score. Also, the AIR score may differentiate perforated from non-perforated appendicitis in pediatric patients with a high level of accuracy.

Diagnosis of Uncomplicated and Complicated Appendicitis in Adults

Background:

Diagnostic work-up of acute appendicitis remains challenging. While some guidelines advise to use a risk stratification based on clinical parameters, others use standard imaging in all patients. As non-operative management of uncomplicated appendicitis has been identified as feasible and safe, differentiation between uncomplicated and complicated appendicitis is of paramount importance. We reviewed the literature to describe the optimal strategy for diagnosis of acute appendicitis.

Methods:

A narrative review about the diagnosis of acute appendicitis in adult patients was conducted. Both diagnostic strategies and goals were analyzed.

Results:

For diagnosing acute appendicitis, both ruling in and ruling out the disease are important. Clinical and laboratory findings individually do not suffice, but when combined in a diagnostic score, a better risk prediction can be made for having acute appendicitis. However, for accurate diagnosis imaging seems obligatory in patients suspected for acute appendicitis. Scoring systems combining clinical and imaging features may differentiate between uncomplicated and complicated appendicitis and may enable ruling out complicated appendicitis. Within conservatively treated patients with uncomplicated appendicitis, predictive factors for non-responsiveness to antibiotics and recurrence of appendicitis need to be defined in order to optimize treatment outcomes.

Conclusion:

Standard imaging increases the diagnostic power for both ruling in and ruling out acute appendicitis. Incorporating imaging features in clinical scoring models may provide better differentiation between uncomplicated and complicated appendicitis. Optimizing patient selection for antibiotic treatment of appendicitis may minimize recurrence rates, resulting in better treatment outcomes.

Validation of the Appendicitis Inflammatory Response (AIR) Score

Background

Patients with suspicion of appendicitis present with a wide range of severity. Score-based risk stratification can optimise the management of these patients. This prospective study validates the Appendicitis Inflammatory Response (AIR) score in patients with suspicion of appendicitis.

Method

Consecutive patients over the age of five with suspicion of appendicitis presenting at 25 Swedish hospital’s emergency departments were prospectively included. The diagnostic properties of the AIR score are estimated.

Results

Some 3878 patients were included, 821 with uncomplicated and 724 with complicated appendicitis, 1986 with non-specific abdominal pain and 347 with other diagnoses. The score performed better in detecting complicated appendicitis (ROC area 0.89 (95% confidence interval (CI) 0.88–0.90) versus 0.83 (CI 0.82–0.84) for any appendicitis, p < 0.001), in patients below age 15 years and in patients with >47 h duration of symptoms (ROC area 0.93, CI 0.90–0.95 for complicated and 0.87, CI 0.84–0.90 for any appendicitis in both categories). Complicated appendicitis is unlikely at AIR score <4 points (Negative Predictive Value 99%, CI 98–100%). Appendicitis is likely at AIR score >8 points, especially in young patients (positive predictive value (PPV) 96%, CI 90–100%) and men (PPV 89%, CI 84–93%).

Conclusions

The AIR score has high sensitivity for complicated appendicitis and identifies subgroups with low probability of complicated appendicitis or high probability of appendicitis. The discriminating capacity is high in children and patients with long duration of symptoms. It performs equally well in both sexes. This verifies the AIR score as a valid decision support.

Trial registration number

https://clinicaltrials.gov/ct2/show/NCT00971438

Quality Outcomes in Appendicitis Care: Identifying Opportunities to Improve Care

INTRODUCTION

Appendicitis is one of the most common causes of acute abdominal pain requiring surgical intervention, but the variability of diagnosis and management continue to challenge the surgeons. Aim: This study assessed patients undergoing appendectomy to identify opportunities to improve diagnostic accuracy and outcomes.

METHODS

An ethically approved retrospective cohort study was undertaken between March 2016 and March 2017 at a single university hospital of all consecutive adult and paediatric patients undergoing appendectomy. Demographic data including age, gender, co-morbidities, presentation and triage timings along with investigation, imaging and operative data were analysed. Appendicitis was defined as acute based on histology coupled with intraoperative grading with the American Association for the Surgery of Trauma (AAST) grades. Complications using the Clavien-Dindo classification along with 30-day re-admission rates and the negative appendectomy rates (NAR) were recorded and categorised greater and less than 25%. The use of scoring systems was assessed, and retrospective scoring performed to compare the Alvarado, Adult Appendicitis Score (AAS) and the Appendicitis Inflammatory Response (AIR) score. Results: A total of 201 patients were studied, 115 male and 86 females, of which 136/201 (67.6%) were adults and 65/201 (32.3%) paediatric. Of the adult group, 83 were male and 53 were female, and of the paediatric group, 32 were male and 33 were female. Median age was 20 years (range: 5 years to 81 years) and no patient below the age of 5 years had an appendectomy during our study period. All patients were admitted via the emergency department and median time from triage to surgical review was 2 h and 38 min, (range: 10 min to 26 h and 10 min). Median time from emergency department review to surgical review, 55 min (range: 5 min to 6 h and 43 min). Median time to operating theatre was 21 h from admission (range: 45 min to 140 h and 30 min). Out of the total patients, 173 (86.1%) underwent laparoscopic approach, 28 (13.9%) had an open approach and 12 (6.9%) of the 173 were converted to open. Acute appendicitis occurred in 166/201 (82.6%). There was no significant association between grade of appendicitis and surgeons' categorical NAR rate (p = 0.07). Imaging was performed in 118/201 (58.7%); abdominal ultrasound (US) in 53 (26.4%), abdominal computed tomography (CT) in 59 (29.2%) and both US and CT in 6 (3%). The best cut-off point was 4 (sensitivity 84.3% and specificity of 65.7%) for AIR score, 9 (sensitivity of 74.7% and specificity of 68.6%) for AAS, and 7 (sensitivity of 77.7% and specificity of 71.4%) for the Alvarado score. Twenty-four (11.9%) were re-admitted, due to pain in 16 (58.3%), collections in 3 (25%), 1 (4.2%) wound abscess, 1 (4.2%) stump appendicitis, 1 (4.2%) small bowel obstruction and 1 (4.2%) fresh rectal bleeding. CT guided drainage was performed in 2 (8.3%). One patient had release of wound collection under general anaesthetic whereas another patient had laparoscopic drain placement. A laparotomy was undertaken in 3 (12.5%) patients with division of adhesions in 1, the appendicular stump removed in 1 and 1 had multiple collections drained.

CONCLUSION

The negative appendectomy and re-admission rates were unacceptably high and need to be reduced. Minimising surgical variance with use of scoring systems and introduction of pathways may be a strategy to reduce NAR. New systems of feedback need to be introduced to improve outcomes.

RIPASA and air scoring systems are superior to alvarado scoring in acute appendicitis: Diagnostic accuracy study

BACKGROUND

Acute appendicitis remains difficult-to-diagnose in spite of being a common acute abdominal condition. Early and correct diagnosis is essential either to proceed with early appendectomy or conservative approach so that complications and negative explorations can be minimised. Scoring systems can help in quick diagnosis and decision making. Though the Alvarado scoring is the widely used system, differences in diagnostic accuracy have been observed when it is applied to varied populations.

MATERIALS AND METHODS

The objective was to find the predictive accuracy of Modified Alvarado score, Appendicitis Inflammatory Response score and Raja Isteri Pengiran Anak Saleha Appendicitis score, in a diagnostic test evaluation study. From first January 2018 to first January 2019, 107 consecutive patients admitted with a diagnosis of suspected appendicitis were assessed with these scores. Sensitivity, specificity, positive and negative predictive value, positive and negative likelihood ratio and area under curve were determined for each.

RESULTS

Negative appendicectomy rate was 15.89%. Sensitivity, specificity, positive predictive value, negative predictive value and diagnostic accuracy were 64.44%, 58.82%, 89.23%, 23.81% and 63.55% respectively for Modified Alvarado; 97.78%, 29.41%, 88%, 71.43% and 86.92% respectively for Appendicitis Inflammatory Response; 87.78%, 76.47%, 95.18%, 54.17% and 85.98% respectively for Raja Isteri Pengiran Anak Saleha Appendicitis. Area under the curve was 0.726797 for Modified Alvarado, 0.946732 for Appendicitis Inflammatory Response and 0.910131 for Raja Isteri Pengiran Anak Saleha Appendicitis.

CONCLUSION

Appendicitis Inflammatory Response score probably is superior to Alvarado in the paediatric population because the variables scored are easy to apply to children, while Alvarado requires children to identify subjective symptoms which may not always be accurate. Appendicitis Inflammatory Response and Raja Isteri Pengiran Anak Saleha Appendicitis are better diagnostic scoring system for acute appendicitis than Modified Alvarado. Also, both these scores can be easily calculated by complete history, detailed clinical examination and basic laboratory investigations.

Validation of a Scoring System to Distinguish Uncomplicated From Complicated Appendicitis

BACKGROUND

Studies have shown that uncomplicated appendicitis can be treated conservatively with antibiotics. It is important to select only those patients with uncomplicated appendicitis when considering conservative management. Recently, a scoring system based on clinical evaluation and ultrasound was developed to improve this selection and aid in shared decision making when considering an antibiotics-first strategy. The aim of this study was to externally validate the scoring system.

MATERIALS AND METHODS

A retrospective cohort study of all adult patients presenting to the emergency department between January 2014 and January 2017 with suspected acute appendicitis based on clinical evaluation and ultrasound was performed. For every patient, a score was calculated using the previously described scoring system. A final diagnosis, subdivided into complicated appendicitis, uncomplicated appendicitis, complicated alternative disease, and uncomplicated alternative disease, was assigned to every patient based on operative findings.

RESULTS

A total of 678 patients with suspected acute appendicitis based on clinical and ultrasonography findings were identified, of whom 175 (25.8%) had complicated appendicitis, 491 (72.4%) had uncomplicated appendicitis, and 12 (1.8%) had an alternative disease. Of the 678 patients, 272 had a score of five points or less, of whom 17 (6.2%) had complicated appendicitis, giving a negative predictive value of 93.8%.

CONCLUSIONS

With the scoring system based on clinical and ultrasonography features, 93.8% of patients predicted to have uncomplicated appendicitis were correctly identified. The scoring system could help identify patients suitable for conservative management in future studies.

Predictive value of scoring systems for the diagnosis of acute appendicitis in emergency department patients: Is there an accurate one?

Background:

Acute appendicitis is one of the challenging surgical conditions presented in the emergency departments. Clinical scoring systems were developed to reduce the negative appendectomy rate and also to avoid unnecessary diagnostic evaluation.

Objectives:

The primary aim was to compare the clinical adequacy of the Alvarado, Acute Inflammatory Response, and the Raja Isteri Pengiran Anak Saleha Appendicitis scores in patients with right lower quadrant pain for the diagnosis of acute appendicitis.

Methods:

This was a prospective and observational study. All patients over the age of 18 years who presented with a complaint of right lower quadrant pain were enrolled. The Alvarado, Acute Inflammatory Response, and Raja Isteri Pengiran Anak Saleha Appendicitis scoring systems were compared. The patients were either admitted or followed-up as out-patient. Face-to-face or telephone follow-up visits were arranged for the patients who did not have surgery and who were not admitted.

Results:

232 patients were included and 14 patients were excluded from the study. Of the 218 patients, 114 patients underwent surgery. Of the 114 patients, 107 patients were pathologically diagnosed with acute appendicitis. It was determined that Raja Isteri Pengiran Anak Saleha Appendicitis score was the most valuable score with 0.88 accuracy, followed by Acute Inflammatory Response (area under the curve = 0.79) and Alvarado (area under the curve = 0.71) scores.

Conclusion:

The accuracy of Raja Isteri Pengiran Anak Saleha Appendicitis scoring system was higher for the diagnosis of acute appendicitis than the other scores. The cut-off of the Raja Isteri Pengiran Anak Saleha Appendicitis score from a 7.5-point threshold provides a practical, non-invasive, rapid diagnostic method that increases acute appendicitis discriminative power in patients presenting with right lower quadrant pain.

Association of Pain Location With Computed Tomography Abnormalities in Emergeny Department Patients With Abdominal Pain

BACKGROUND

Over the last decade the usage of computed tomography (CT) imaging has risen dramatically in emergency department (ED) patients with abdominal pain. Recognizing the potential disadvantages of overuse of CT imaging, efforts are being made to reduce imaging.

OBJECTIVE

We determined the operating characteristics for location of abdominal pain for the entities of acute appendicitis, diverticulitis, and intestinal obstruction. We hypothesized that patients with pain localized to the upper abdomen would be less likely to have CT abnormalities than those with lower abdominal pain.

METHODS

This is a prospective, observational registry of ED patients with abdominal pain, performed in an academic, suburban ED with an annual census of 110,000. Presence of clinically significant CT abnormalities (e.g., appendicitis, diverticulitis, bowel obstruction) were recorded along with clinical variables including laboratory values, vital signs, reported location of pain, location of tenderness on examination, and physician pretest probability.

RESULTS

A convenience sample of 1154 patients was enrolled. Of all patients, 273 cases (24%) had abnormal CT results, including appendicitis (n = 95), diverticulitis (n = 133), and bowel obstruction (n = 49). Right upper quadrant pain was negatively associated with abnormal CT (p = 0.02). Clinician gestalt was highly specific, but lacked sensitivity for the diagnosis of appendicitis, diverticulitis, and obstruction. Twenty-four percent of patients diagnosed with appendicitis had no right lower quadrant pain or tenderness, and 7% of patients with diverticulitis had no left lower quadrant pain or tenderness.

CONCLUSIONS

Localization of abdominal pain by history or physical examination is not sufficient to accurately diagnose intra-abdominal pathology, especially cases of acute appendicitis, diverticulitis, or intestinal obstruction.

Acute Appendicitis Review: Background, Epidemiology, Diagnosis, and Treatment

Appendicitis is a common occurrence in both the adult and pediatric populations. The condition most commonly occurs between the ages of 10 and 20 years with a lifetime risk of 8.6% and 6.7% for males and females respectively. Its diagnosis focuses on clinical presentation and imaging modalities classified according to scoring systems such as the Alvarado scoring system. A number of imaging modalities can be used, with CT being the most common one. For acute appendicitis, surgical intervention is considered to be the gold standard of treatment. However, recent research has focused on other modalities of treatment including antibiotics and endoscopic retrograde appendicitis therapy (ERAT) to avoid surgical complications.

Analysis of CT characteristics in the diagnosis of Schistosoma japonicum associated appendicitis with clinical and pathological correlation: a diagnostic accuracy study

PURPOSE

To clarify unique non-contrast CT (NCCT) characteristics for early recognition of Schistosomal associated appendicitis (SAA) differentiating from Non-schistosomal associated appendicitis (NSA).

MATERIAL AND METHODS

Clinical and pathological data of 50 cases with SAA and 60 cases with NSA who underwent emergency appendectomy were retrospectively compared to pre-surgical NCCT features such as direct and indirect signs of acute appendicitis as well as appendicoliths, colon calcifications as diagnostic criteria. Statistical methods such as Chi-square (χ²), t-tests, Principal component analysis (PCA), Binary Logistic regression (LR) and Factor Analysis (FA) were utilized to observe differences and isolate recognizable CT features of SAA. Pre and post hoc diagnostic performance of all criteria was calculated as sensitivity, specificity, and the Odds Ratio (OR).

RESULTS

Age > 50 years, diameter > 13 mm, pneumatosis, peri appendiceal abscess, focal wall defect, perforation; Orbital, linear and point types of appendicular wall calcifications; sigmoid colon and cecal curvilinear calcifications were observed as unique characteristics with a sensitivity of 84-95% and specificity of 91-98% in predicting SAA by OR of 6.2 times. Pre and post hoc hypothetical analysis did not show any significance for all other factors.

CONCLUSION

Factors such as elderly age, CT features such as larger appendicular diameter, appendicular wall calcifications along with sigmoid colon, and cecal calcifications, signs of perforation or abscess are characteristic for early recognition of SAA.

Comparison of the use of Alvarado and AIR scores as an adjunct to the clinical diagnosis of acute appendicitis in the pediatric population

Background

Acute appendicitis is one of the most common causes of acute abdominal pain with an incidence of 1.17 per 1000 and lifetime risk of approximately 7%. It remains the most common indication for emergency abdominal surgery in childhood. Diagnosis of acute appendicitis is particularly difficult in young women and the pediatric population. In the USA, CT imaging is used to avert diagnostic dilemma, however the procedure is associated with radiation risk in this vulnerable population. Additionally, the procedure has high cost and variable availability.

Methods

A retrospective study involving all suspected pediatric cases of appendicitis between the ages of 5 and 17 who were operated on between 2012 and 2015 was carried out. Data were collated from clinical notes on age, sex, ultrasound findings; postoperative complications, white cell count, neutrophils, C-reactive protein, histology result, and number of days to theater. All patients in the time period were retrospectively scored on the Alvarado and Appendicitis Inflammatory Response (AIR) scores.

Results

A total of 239 patients between 11 and 17 (mean 13.6±SE) years of age were included in the study. Of these, 79 had preoperative ultrasound, of which 52 were negative, and only one patient had CT scan. 213 of the patients had an appendicectomy and 26 had diagnostic laparoscopy with no appendicectomy. Of the 213 appendixes removed, 71 were histopathologically normal, giving a negative appendectomy rate of 33.3%. 28 appendixes were perforated. The average number of days from admission to theater was 1.0 SE in males and 1.424 in females (p=0.0498). The average number of days from admission to theater in those who had ultrasound was 2.03 days compared with 0.75 in those who did not have ultrasound (p<0.0001). AIR scoring that was high and medium risk showed slightly lower negative appendicectomy rates but not significantly different.

Conclusions

Our study has found no significant difference between the AIR scores and Alvarado. There is a role for scoring systems to be used to aid in the decision to undergo imaging and as an adjunct to clinical diagnosis.

Diagnosis of pain in the right iliac fossa. A new diagnostic score based on Decision-Tree and Artificial Neural Network Methods

INTRODUCTION

Pain in the right iliac fossa (RIF) continues to pose diagnostic challenges. The objective of this study is the development of a RIF pain diagnosis model based on classification trees of type CHAID (Chi-Square Automatic Interaction Detection) and on an artificial neural network (ANN).

METHODS

Prospective study of 252 patients who visited the hospital due to RIF pain. Demographic, clinical, physical examination and analytical data were registered. Patients were classified into 4 groups: NsP (nonspecific RIFP group), AA (acute appendicitis), NIRIF (RIF pain with no inflammation) and IRIF (RIF pain with inflammation). A CHAID-type classification tree model and an ANN were constructed. The classic models (Alvarado [ALS], Appendicitis Inflammatory Response [AIR] and Fenyö-Linberg [FLS]) were also evaluated. Discrimination was assessed using ROC curves (AUC [95% CI]) and the correct classification rate (CCR).

RESULTS

53% were men. Mean age 33.3±16 years. The largest group was the NsP (45%), AA (37%), NRIF (12%) and IRIF (6%). The analytical model results were: ALS (0.82 [0.76-0.87]), AIR (0.83 [0.77-0.88]) and FLS (0.88 [0.84-0.92]). CHAID determined 10 decision groups: 3 with high probability for NsP, 3 high for AA and 4 special groups with no predominant diagnosis. CCR of ANN and CHAID were 75% and 74.2%, respectively.

CONCLUSIONS

The methodology based on CHAID-type classification trees establishes a diagnostic model based on four pain groups in RIF and generates decision rules that can help us in the diagnosis of processes with RIF pain.

The Unacceptable Morbidity of Negative Laparoscopic Appendicectomy

BACKGROUND

One of the most common acute conditions managed by general surgeons is acute appendicitis. Laparoscopic appendicectomy (LA) is the surgical technique used by many surgeons. The aims of this study were to define our unit's negative appendicectomy rate and compare the outcomes associated with removal of a normal appendix with those for acute appendicitis in patients having LA.

METHODS

A single-centre retrospective case note review of patients undergoing LA for suspected acute appendicitis was performed. Patients were divided into positive and negative appendicectomy groups based on histology results. The positive group was subdivided into uncomplicated and complicated (perforated and/or gangrenous) appendicitis. Outcomes were compared between groups.

RESULTS

There were 1413 patients who met inclusion criteria, 904 in the positive group and 509 in the negative group, an overall negative appendicectomy rate of 36.0%. Morbidity rates (6.3% vs. 6.9%; P = 0.48) and types of morbidity were the same for negative appendicectomy and uncomplicated appendicitis. There was no significant difference in complication severity (all P > 0.17) or length of stay (2.3 vs. 2.6 days; P = 0.06) between negative appendicectomy and uncomplicated appendicitis groups. Patients with complicated appendicitis had a significantly higher morbidity rate compared to negative and uncomplicated groups (20.1% vs. 6.3% and 20.1% vs. 6.9%; both P < 0.001).

CONCLUSION

The morbidity of negative LA is the same as LA for uncomplicated appendicitis. The morbidity of LA for complicated appendicitis is significantly higher. The selection criteria for LA in our unit needs to be reviewed to address the high negative appendicectomy rate and avoid unnecessary surgery and its associated morbidity.

Logistic regression model to predict acute uncomplicated and complicated appendicitis

INTRODUCTION

While patients with acute uncomplicated appendicitis may be treated conservatively, those who suffer from complicated appendicitis require surgery. We describe a logistic regression equation to calculate the likelihood of acute uncomplicated appendicitis and complicated appendicitis in patients presenting to the emergency department with suspected acute appendicitis.

MATERIALS AND METHODS

A cohort of 895 patients who underwent appendicectomy were analysed retrospectively. Depending on the final histology, patients were divided into three groups; normal appendix, acute uncomplicated appendicitis and complicated appendicitis. Normal appendix was considered the reference category, while acute uncomplicated appendicitis and complicated appendicitis were the nominal categories. Multivariate and univariate regression models were undertaken to detect independent variables with significant odds ratio that can predict acute uncomplicated appendicitis and complicated appendicitis. Subsequently, a logistic regression equation was generated to produce the likelihood acute uncomplicated appendicitis and complicated appendicitis.

RESULTS

Pathological diagnosis of normal appendix, acute uncomplicated appendicitis and complicated appendicitis was identified in 188 (21%), 525 (59%) and 182 patients (20%), respectively. The odds ratio from a univariate analysis to predict complicated appendicitis for age, female gender, log2 white cell count, log2 C-reactive protein and log2 bilirubin were 1.02 (95% confidence interval, CI, 1.01, 1.04), 2.37 (95% CI 1.51, 3.70), 9.74 (95% CI 5.41, 17.5), 1.57 (95% CI 1.40, 1.74), 2.08 (95% CI 1.56, 2.76), respectively. For the same variable, similar odds ratios were demonstrated in a multivariate analysis to predict complicated appendicitis and univariate and multivariate analysis to predict acute uncomplicated appendicitis.

CONCLUSIONS

The likelihood of acute uncomplicated appendicitis and complicated appendicitis can be calculated by using the reported predictive equations integrated into a web application at www.appendistat.com. This will enable clinicians to determine the probability of appendicitis and the need for urgent surgery in case of complicated appendicitis.

Laparoscopic Appendectomy in the Setting of Clinical Prediction Rules

PURPOSE

Acute appendicitis (AA) is the most frequent surgical entity in the emergency department, but its correct diagnosis remains challenging. To improve diagnosis, clinical prediction rules (CPRs) have been created to establish objective scores for the probability of suffering AA. In this study, we establish scores indicating whether laparoscopy would be superior to clinical observation or repeat diagnostic test.

METHODS

A retrospective observational study was conducted with 433 patients submitted to surgery for suspected AA using a laparoscopic approach. The Alvarado, Raja Isteri Pengiran Anak Saleha Appendicitis, appendicitis inflammatory response, and adult appendicitis score scales were applied in each case to establish a high, medium, or low probability of suffering AA.

RESULTS

Of the 433 patients analyzed, 381 (88.0%) had AA. Twelve (2.8%) were converted to open surgery, and complications were observed in 54 (12.5%) cases. The CPRs studied showed statistically significant differences between AA and negative appendectomies. However, in patients with intermediate probability scores, the diagnostic accuracy of the CPRs evaluated was not adequate.

CONCLUSIONS

Laparoscopic surgery can serve as a diagnostic tool for patients with intermediate AA probability scores because of its low associated morbidity and mortality and because it affords a direct diagnosis of the problem, allowing determination of the appropriate treatment.

Clinical Prediction Rules for Appendicitis in Adults: Which Is Best?

BACKGROUND

Clinical prediction rules (CPRs) provide an objective method of assessment in the diagnosis of acute appendicitis. There are a number of available CPRs for the diagnosis of appendicitis, but it is unknown which performs best.

AIM

The aim of this study was to identify what CPRs are available and how they perform when diagnosing appendicitis in adults.

METHOD

A systematic review was performed in accordance with the PRISMA guidelines. Studies that derived or validated a CPR were included. Their performance was assessed on sensitivity, specificity and area under curve (AUC) values.

RESULTS

Thirty-four articles were included in this review. Of these 12 derived a CPR and 22 validated these CPRs. A narrative analysis was performed as meta-analysis was precluded due to study heterogeneity and quality of included studies. The results from validation studies showed that the overall best performer in terms of sensitivity (92%), specificity (63%) and AUC values (0.84-0.97) was the AIR score but only a limited number of studies investigated at this score. Although the Alvarado and Modified Alvarado scores were the most commonly validated, results from these studies were variable. The Alvarado score outperformed the modified Alvarado score in terms of sensitivity, specificity and AUC values.

CONCLUSION

There are 12 CPRs available for diagnosis of appendicitis in adults. The AIR score appeared to be the best performer and most pragmatic CPR.

Measuring Anatomic Severity in Pediatric Appendicitis: Validation of the American Association for the Surgery of Trauma Appendicitis Severity Grade

OBJECTIVE

To assess whether the American Association for the Surgery of Trauma (AAST) grading system accurately corresponds with appendicitis outcomes in a US pediatric population.

STUDY DESIGN

This single-institution retrospective review included patients <18 years of age (n = 331) who underwent appendectomy for acute appendicitis from 2008 to 2012. Demographic, clinical, procedural, and follow-up data (primary outcome was measured as Clavien-Dindo grade of complication severity) were abstracted. AAST grades were generated based on intraoperative findings. Summary, univariate, and multivariable regression analyses were performed to compare AAST grade and outcomes.

RESULTS

Overall, 331 patients (46% female) were identified with a median age of 12 (IQR, 8-15) years. Appendectomy was laparoscopic in 90% and open in 10%. AAST grades included: Normal (n = 13, 4%), I (n = 152, 46%), II (n = 90, 27%), III (n = 43, 13%), IV (n = 24 7.3%), and V (n = 9 2.7%). Increased AAST grade was associated with increased Clavien-Dindo severity, P =.001. The overall complication rate was 13.6% and was comprised by superficial surgical site infection (n = 13, 3.9%), organ space infection (n = 15, 4.5%), and readmission (n = 17, 5.1%). Median duration of stay increased with AAST grade (P < .0001). Nominal logistic regression identified the following as predictors of any complication (P < .05): AAST grade and febrile temperature at admission.

CONCLUSIONS

The AAST appendicitis grading system is valid in a single-institution pediatric population. Increasing AAST grade incrementally corresponds with patient outcomes including increased risk of complications and severity of complications. Determination of the generalizability of this grading system is required.

Which One is Better? Comparison of the Acute Inflammatory Response, Raja Isteri Pengiran Anak Saleha Appendicitis and Alvarado Scoring Systems

Purpose

Acute appendicitis (AA) is one of the most common causes of an acute abdomen. The accuracies of the Alvarado and the acute inflammatory response (AIR) scores in the diagnosis of appendicitis is very low in Asian populations, so a new scoring system, the Raja Isteri Pengiran Anak Saleha Appendicitis (RIPASA) system, was designed recently. We applied and compared the Alvarado, AIR, and RIPASA scores in the diagnoses of appendicitis in the Iranian population.

Methods

We prospectively compared the RIPASA, Alvarado, and AIR systems by applying them to 100 patients. All the scores were calculated for patients who presented with right quadrant pain. Appendectomies were performed; then, the postoperative pathology reports were correlated with the scores. Scores of 8, 7, and 5 or more are optimal cutoffs for the RIPASA, Alvarado, and AIR scoring systems, respectively. The sensitivities, specificities, positive predictive values, negative predictive values (NPVs), positive and negative likelihood ratios (LRs) for the 3 systems were determined.

Results

The sensitivity and the specificity of the RIPASA score were 93.18% and 91.67%, respectively. The sensitivities of the Alvarado and the AIR scores were both 78.41%. The specificities of the Alvarado and the AIR scores were 100% and 91.67%, respectively. The RIPASA score correctly classified 93% of all patients confirmed with histological AA compared with 78.41% for the Alvarado and the AIR scores.

Conclusion

The RIPASA scoring system had more sensitivity, better NPV, a positive LR, and a less negative LR for the Iranian population whereas the Alvarado scoring system was more specific.

Developing and validating of Ramathibodi Appendicitis Score (RAMA-AS) for diagnosis of appendicitis in suspected appendicitis patients

Background

Diagnosis of appendicitis is still clinically challenging where resources are limited. The purpose of this study was to develop and externally validate Ramathibodi Appendicitis Score (RAMA-AS) in aiding diagnosis of appendicitis.

Methods

A two-phase cross-sectional study (i.e., derivation and validation) was conducted at Ramathibodi Hospital (for derivation) and at Thammasat University Hospital and Chaiyaphum Hospital (for validation). Patients with abdominal pain and suspected of having appendicitis were enrolled. Multiple logistic regression was applied to develop a parsimonious model. Calibration and discrimination performances were assessed. In addition, our RAMA-AS was compared with Alvarado’s score performances using ROC curve analysis.

Results

The RAMA-AS consisted of three domains with seven predictors including symptoms (i.e., progression of pain, aggravation of pain, and migration of pain), signs (i.e., fever and rebound tenderness), and laboratory tests (i.e., white blood cell count (WBC) and neutrophil). The model fitted well with data, and it performed better discrimination than the Alvarado score with C-statistics of 0.842 (95% CI 0.804, 0.881) versus 0.760 (0.710, 0.810). Internal validation by bootstrap yielded Sommer’s D of 0.686 (0.608, 0.763) and C-statistics of 0.848 (0.846, 0.849). The C-statistics of two external validations were 0.853 (0.791, 0.915) and 0.813 (0.736, 0.892) with fair calibrations.

Conclusion

RAMA-AS should be a useful tool for aiding diagnosis of appendicitis with good calibration and discrimination performances.

Electronic supplementary material

The online version of this article (10.1186/s13017-017-0160-3) contains supplementary material, which is available to authorized users.

Randomized clinical trial of Appendicitis Inflammatory Response score-based management of patients with suspected appendicitis

BACKGROUND

The role of imaging in the diagnosis of appendicitis is controversial. This prospective interventional study and nested randomized trial analysed the impact of implementing a risk stratification algorithm based on the Appendicitis Inflammatory Response (AIR) score, and compared routine imaging with selective imaging after clinical reassessment.

METHOD

Patients presenting with suspicion of appendicitis between September 2009 and January 2012 from age 10 years were included at 21 emergency surgical centres and from age 5 years at three university paediatric centres. Registration of clinical characteristics, treatments and outcomes started during the baseline period. The AIR score-based algorithm was implemented during the intervention period. Intermediate-risk patients were randomized to routine imaging or selective imaging after clinical reassessment.

RESULTS

The baseline period included 1152 patients, and the intervention period 2639, of whom 1068 intermediate-risk patients were randomized. In low-risk patients, use of the AIR score-based algorithm resulted in less imaging (19·2 versus 34·5 per cent; P < 0·001), fewer admissions (29·5 versus 42·8 per cent; P < 0·001), and fewer negative explorations (1·6 versus 3·2 per cent; P = 0·030) and operations for non-perforated appendicitis (6·8 versus 9·7 per cent; P = 0·034). Intermediate-risk patients randomized to the imaging and observation groups had the same proportion of negative appendicectomies (6·4 versus 6·7 per cent respectively; P = 0·884), number of admissions, number of perforations and length of hospital stay, but routine imaging was associated with an increased proportion of patients treated for appendicitis (53·4 versus 46·3 per cent; P = 0·020).

CONCLUSION

AIR score-based risk classification can safely reduce the use of diagnostic imaging and hospital admissions in patients with suspicion of appendicitis. Registration number: NCT00971438 ( http://www.clinicaltrials.gov).

Pediatric appendicitis: state of the art review

Appendicitis is a common cause of abdominal pain in children. The diagnosis and treatment of the disease have undergone major changes in the past two decades, primarily as a result of the application of an evidence-based approach. Data from several randomized controlled trials, large database studies, and meta-analyses have fundamentally affected patient care. The best diagnostic approach is a standardized clinical pathway with a scoring system and selective imaging. Non-operative management of simple appendicitis is a reasonable option in selected cases, with the caveat that data in children remain limited. A minimally invasive (laparoscopic) appendectomy is the current standard in US and European children's hospitals. This article reviews the current 'state of the art' in the evaluation and management of pediatric appendicitis.