Predictive factors of negative appendectomy in children

Ultrasound Assessment in Children With Suspected Appendicitis: Time to Revise Diagnostic Criteria: A Prospective Cohort Study

Background: Although ultrasound is considered the gold standard for the evaluation of children with suspected appendicitis, there is still much debate about the most accurate ultrasound findings. The purpose of this study was to define the best ultrasound signs that could ultimately improve the diagnostic accuracy of ultrasound for diagnosing pediatric acute appendicitis, and to differentiate between simple appendicitis and complicated appendicitis. Patients and Methods: After approval by our Institutional Review Board, a prospective study was carried out from January 1, 2022, to July 31, 2023, in a pediatric emergency department. We included all patients aged under 14 years with suspected appendicitis and ultrasound-visualized appendix. Results: A total of 550 patients presented with suspected appendicitis during the study period. Of these children, 411 had an ultrasound-visualized appendix. Our patients' mean age was 9.4 years. The best positive predictive value of ultrasound was found for appendiceal diameter ≥7.5 mm. The combination of an appendiceal diameter <6 mm and the lack of peri-appendiceal free fluid on ultrasound rules out the diagnosis of appendicitis. The best diagnostic accuracy of ultrasound, which was 92%, was achieved for appendix diameters ≥6.5 mm. The sonographic sign giving the best ultrasound accuracy for diagnosing complicated appendicitis was an appendix diameter ≥9 mm. Conclusions: In conclusion, our present study demonstrated that appendiceal diameter ≥6.5 mm is the gold standard for diagnosing appendicitis in pediatric patients. The combination of an appendiceal diameter <6 mm and the lack of peri-appendiceal free fluid on ultrasound would rule out appendicitis.

Predictive Factors of Acute Appendicitis in Children With Non-Visualized Appendix on Ultrasound: A Prospective Cohort Study

Background: Most studies have demonstrated the high accuracy of ultrasound for the diagnosis of acute appendicitis (AA) in children. However, the lack of visualization of the appendix on ultrasound is usually a challenge. The aim of this study was to identify any factors that might help the physician make the right decision when dealing with a child with suspected appendicitis and an appendix not seen on ultrasound. Patients and Methods: After receiving Institutional Review Board approval, we conducted a prospective study in a pediatric emergency department from January 1, 2022, to December 31, 2022. All children under 14 years of age with suspected AA and an appendix not visualized on ultrasound were included. Results: During the study period, 333 children presented with suspected AA. Of these patients, 106 had an appendix not seen on ultrasound. Our patients' median age was 10 years (interquartile range [IQR], 8-11 years), with 54.7% (n = 58) of children being female. Twenty-five (23.6%) were ultimately diagnosed with AA based on pathologic examination. Multivariable logistic regression analysis revealed that Alvarado score ≥6 and increased peri-appendiceal fat echogenicity were predictive for AA. The combination of these two factors provided a positive predictive value of 100%. A white blood cell (WBC) count ≤10 × 109/L and/or a C-reactive protein (CRP) level ≤6 mg/L makes the diagnosis of appendicitis unlikely. Conclusions: In conclusion, our study demonstrated that an Alvarado score at or above six and increased peri-appendiceal fat echogenicity are independent predictive factors of AA in children with non-visualized appendix on ultrasound. The combination of these two factors would confirm the diagnosis of AA in these patients.

Non-operative treatment of acute appendicitis in children: clinical efficacy of amoxicillin-clavulanic acid in a retrospective single-centre study

BACKGROUND

The success rate of non-operative treatment (NOT) of acute uncomplicated appendicitis (AUA) in children varies from 65% to 95%. There are no recommendations on the appropriate antibiotic therapy.

OBJECTIVE

To determine the clinical efficacy of amoxicillin-clavulanic acid for NOT of AUA in children.

METHODS

Design: Cross-sectional study in a single medical centre.

SETTINGS

Emergency department and Paediatric Visceral Surgery department of the Children Hospital in Toulouse, France.

PATIENTS

Patients 5-15 years old who were diagnosed with appendicitis, (1) With abdominal pain and a first episode of acute appendicitis, (2) With no radiological or ultrasound evidence of appendicolith, appendiceal perforation, pelvic abscess nor peritonitis, and (3) With non-septic general aspect, were included.

INTERVENTIONS

NOT consisted of hospital admission. The antibiotic treatment was a combination of amoxicillin and clavulanic acid (80 mg/kg/day of amoxicillin): intravenous regimen during 48 hours followed by oral route during 7 days.

MAIN OUTCOME MEASURE

Success rate of amoxicillin-clavulanic acid NOT in children with AUA at 2 years.

RESULTS

The initial success rate of amoxicillin-clavulanic acid NOT in children with AUA was 100% (104/104 patients). The success rate at 2 years was 85.6% (89/104) at discharge. None of the 15 patients who underwent surgery after recurrence of appendicitis presented with peritonitis, appendiceal perforation nor pelvic abscess.

CONCLUSION

Narrowed antibiotic therapy with amoxicillin and clavulanic acid seems to be an alternative to surgery in children with AUA. It is necessary to wait for the results of ongoing studies to confirm these results.

Diagnostic Accuracy of Suspected Appendicitis: A Comparative Analysis of Misdiagnosed Appendicitis in Children

OBJECTIVE

When evaluating suspected appendicitis, limited data support quality benchmarks for negative appendectomy (NA); none exist for delayed diagnosis of appendicitis (DDA). The objectives of this study are the following: (1) to provide preliminary evidence supporting a quality benchmark for DDA and 2) to compare presenting features and diagnostic evaluations of children with NA and DDA with those with pathology-confirmed appendicitis (PCA) diagnosed during initial emergency department (ED) encounter.

METHODS

Secondary analysis of data from a QI project designed to reduce the use computed tomography when evaluating suspected appendicitis using a case-control design. Patients undergoing appendectomy in an academic tertiary care children's hospital system between January 1, 2015, and December 31, 2016 (n = 1,189) were eligible for inclusion in this case-control study. Negative appendectomy was defined as no pathologic change or findings consistent with a different diagnosis. Delayed diagnosis of appendicitis was defined as patients undergoing appendectomy within 7 days of a prior ED visit for a related complaint. Controls of PCA (n = 150) were randomly selected from all cases undergoing appendectomy.

RESULTS

There were 42 NA (3.5%) and 31 DDA (2.6%). Cases of PCA and NA exhibited similar histories, examination findings, and underwent comparable diagnostic evaluations. Cases of PCA more frequently demonstrated a white blood cell count greater than 10 × 103/μL (85% vs 67%; P = 0.01), a left-shift (77% vs 45%; P < 0.001), and an ultrasound interpretation with high probability for appendicitis (73% vs 54%; P = 0.03). Numerous significant differences in history, examination findings, and diagnostic tests performed existed between cases of PCA and DDA.

CONCLUSIONS

Children with PCA and NA present similarly and undergo comparable evaluations resulting in appendectomy. A 3% to 4% NA rate may be unavoidable given these similarities. Presenting features in DDA significantly differ from those of PCA. An irreducible proportion of appendicitis diagnoses may be delayed.

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.

Diagnostic accuracy of laboratory and ultrasound findings in patients with a non-visualized appendix

Ultrasound (US) and laboratory testing are initial diagnostic tests for acute appendicitis. A diagnostic dilemma develops when the appendix is not visualized on US. Objective: To determine if specific US findings and/or laboratory results predict acute appendicitis when the appendix is not visualized. Methods: A prospective study was conducted on children (birth-18 yrs) presenting to the pediatric emergency department with suspected acute appendicitis who underwent right lower quadrant US. Children with previous appendectomy, US at another facility, or eloped were excluded. US findings analyzed: inflammatory changes, right lower quadrant and lower abdominal fluid, tenderness during US exam and lymph nodes. Diagnoses were confirmed via surgical pathology. Results 1252 subjects were enrolled, 60.8% (762) had appendix visualized and 39.1% (490) did not. In children where the appendix was not seen, 6.7% [33] were diagnosed with appendicitis. Among patients with a non-visualized appendix, the likelihood of appendicitis was significantly greater if: inflammatory changes in the RLQ (OR 18.0, 95% CI 4.5-72.1), CRP >0.5 mg/dL (OR 2.64, 95% CI 1.0-6.8), or WBC > 10 (OR 4.36, 95% CI 1.66-11.58). Duration of abdominal pain >3 days was significantly less likely associated with appendicitis in this model (OR 0.34, 95% CI 0.003-0.395). Combined, the absence inflammatory changes, CRP < 0.5 mg/dL, WBC < 10, and pain, ≤3 days had a NPV of 94.0%. Conclusion When the appendix is not visualized on US, predictors for appendicitis include the presence of inflammatory changes in the RLQ, an elevated WBC/CRP and abdominal pain <3 days.