C-reactive protein value is a strong predictor of acute appendicitis in young children

PAN-Immune inflammation value: a new biomarker for diagnosing appendicitis in children??

BACKGROUND

This study investigates the potential of the pan-immune-inflammation values (PIV) index as a biomarker for diagnosing acute appendicitis in children and compares its performance with other systemic inflammatory markers.

METHODS

A retrospective analysis of 1,514 pediatric patients aged 0-18 years with abdominal pain admitted between 2019 and 2023 was conducted. Patients were categorized into complicated, non-complicated appendicitis, negative appendectomy, and non-surgical treatment groups. Demographic and laboratory data were recorded, and PIV, Systemic Inflammation Index (SII), Systemic Inflammation Response Index (SIRI), Neutrophil-to-Lymphocyte Ratio (NLR), and Platelet-to-Lymphocyte Ratio (PLR) indices were calculated. Receiver Operating Characteristic (ROC) analysis was used to assess predictive performance, with optimal cut-offs evaluated for sensitivity, specificity, and multiple logistic regression (MLR) analyses.

RESULTS

Based on Area Under the Curve (AUC), C-reactive Protein (CRP), lymphocyte, and PLR showed weak predictive value, while White Blood Cell Count (WBC), neutrophil, monocyte, NLR, SII, SIRI, and PIV demonstrated poor predictive value for appendicitis. Optimal cut-offs were 3.40 for NLR, 134.5 for PLR, 1010.3 for SII, 3.47 for SIRI, and 919.3 for PIV, with sensitivity and specificity values of 78.7%, 47.1% for NLR; 64.7%, 47.5% for PLR; 75.6%, 52% for SII; 71.5%, 57.3% for SIRI; and 72.2%, 54.1% for PIV. In the MLR model, PIV above 919.3 increased appendicitis likelihood 2.67-fold (95% Confidence Interval: 2.16-3.37).

CONCLUSION

Although PIV demonstrated potential as a novel biomarker for pediatric appendicitis, its diagnostic utility remains limited without supplementary clinical and radiological data. Larger prospective studies are recommended to validate these findings and improve clinical decision-making. PIV may serve as a supplementary tool in diagnosing pediatric appendicitis when used alongside other markers and diagnostic methods.

TRIAL REGISTRATION

'retrospectively registered'.

C-reactive protein and digestive pathologies: A narrative review for daily clinical use

The aim of this narrative review is to familiarize clinicians, especially digestive surgeons, to adequately use of serum C-reactive protein as a reliable noninvasive biomarker in diverse practical clinical situations. We hope that the review will help clinicians for their decision-making when facing various digestive diseases including operative and nonoperative pathologies such as anastomotic leakage, pancreatitis, emergency situation, and digestive cancer management and prognosis.

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.

Observation Safely Reduces the Use of the Computerized Tomography in Medium-to-Low-Risk Patients with Suspected Acute Appendicitis: Results of a Randomized Controlled Trial

Objectives-The objective was to compare the effectiveness of observation in standard-of-care computed tomography (CT) in adult patients with suspected acute appendicitis (AA). Methods-Patients with clinically suspected AA and inconclusive diagnosis after primary clinical examination, laboratory examination, and transabdominal ultrasound (TUS) were eligible for the study, and they were randomized (1:1) to parallel groups: observation-group patients were observed for 8-12 h and then, repeated clinical and laboratory examinations and TUS were performed; CT group (control group) patients underwent abdominopelvic CT scan. The study utilized Statistical Analysis System 9.2 for data analysis, including tests, logistic regression, ROC analysis, and significance evaluation. Patients were enrolled in the study at Vilnius University Hospital Santaros Klinikos in Lithuania between December 2018 and June 2021. Results-A total of 160 patients (59 men, 101 women), with a mean age of 33.7 ± 14.71, were included, with 80 patients in each group. Observation resulted in a reduced likelihood of a CT scan compared with the CT group (36.3% vs. 100% p < 0.05). One diagnostic laparoscopy was performed in the observation group; there were no cases of negative appendectomy (NA) in the CT group. Both conditional CT and observation pathways resulted in high sensitivity and specificity (97.7% and 94.6% vs. 96.7% and 95.8%). Conclusions-Observation including the repeated evaluation of laboratory results and TUS significantly reduces the number of CT scans without increasing NA numbers or the number of complicated cases.

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.

Diagnosis and treatment of acute appendicitis: 2020 update of the WSES Jerusalem guidelines

BACKGROUND AND AIMS

Acute appendicitis (AA) is among the most common causes of acute abdominal pain. Diagnosis of AA is still challenging and some controversies on its management are still present among different settings and practice patterns worldwide. In July 2015, the World Society of Emergency Surgery (WSES) organized in Jerusalem the first consensus conference on the diagnosis and treatment of AA in adult patients with the intention of producing evidence-based guidelines. An updated consensus conference took place in Nijemegen in June 2019 and the guidelines have now been updated in order to provide evidence-based statements and recommendations in keeping with varying clinical practice: use of clinical scores and imaging in diagnosing AA, indications and timing for surgery, use of non-operative management and antibiotics, laparoscopy and surgical techniques, intra-operative scoring, and peri-operative antibiotic therapy.

METHODS

This executive manuscript summarizes the WSES guidelines for the diagnosis and treatment of AA. Literature search has been updated up to 2019 and statements and recommendations have been developed according to the GRADE methodology. The statements were voted, eventually modified, and finally approved by the participants to the consensus conference and by the board of co-authors, using a Delphi methodology for voting whenever there was controversy on a statement or a recommendation. Several tables highlighting the research topics and questions, search syntaxes, and the statements and the WSES evidence-based recommendations are provided. Finally, two different practical clinical algorithms are provided in the form of a flow chart for both adults and pediatric (< 16 years old) patients.

CONCLUSIONS

The 2020 WSES guidelines on AA aim to provide updated evidence-based statements and recommendations on each of the following topics: (1) diagnosis, (2) non-operative management for uncomplicated AA, (3) timing of appendectomy and in-hospital delay, (4) surgical treatment, (5) intra-operative grading of AA, (6) ,management of perforated AA with phlegmon or abscess, and (7) peri-operative antibiotic therapy.