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Tong L, Nataraja RM, VanHaltren K, Sulaksana TH, Vinycomb TI, Pacilli M. The utility of sonographic signs to diagnose simple and complicated appendicitis in children. Pediatr Surg Int 2023; 39:114. [PMID: 36764977 PMCID: PMC9918567 DOI: 10.1007/s00383-023-05397-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/31/2023] [Indexed: 02/12/2023]
Abstract
BACKGROUND Acute appendicitis is classified into simple (SA) and complicated (CA). Ultrasound scans (USS) can be useful in clinically equivocal cases, by visualising primary and secondary signs. This study explores the utility of sonographic signs to diagnose and differentiate appendicitis in children. METHODS Single-centre retrospective cohort study over a 2-year period. Consecutive USS for suspected appendicitis were included; sonographic signs were extracted from standardised institutional worksheets. USS results were compared with pre-defined intraoperative criteria for SA and CA, confirmed with histological analysis. Data are reported as median [interquartile range], percentages (number), area under the curve (AUC), conventional diagnostic formulae and adjusted odds ratios following multiple logistic regression (p < 0.05 considered significant). RESULTS A total of 934 USS were included, with median age 10.7 [8.0-13.4] years, majority were female (54%). One quarter (n = 226) had SA, 12% (n = 113) had CA, 61% (n = 571) had no appendectomy and 3% (n = 24) had negative appendicectomy. Appendix visualisation rate on USS was 61% (n = 569), with 62% (n = 580) having a conclusive report. Sonographic signs suggesting appendicitis included an appendiceal diameter > 7 mm (AUC 0.92, [95% CI: 0.90-0.94]), an appendicolith (p = 0.003), hyperaemia (p = 0.001), non-compressibility (p = 0.029) and no luminal gas (p = 0.004). Secondary sonographic signs included probe tenderness (p < 0.001) and peri-appendiceal echogenic fat (p < 0.001). Sonographic signs suggesting CA over SA comprised a diameter > 10.1 mm (AUC 0.63, [95% CI: 0.57-0.69]), an appendicolith (p = 0.003) and peri-appendiceal fluid (p = 0.004). CONCLUSION Presence of specific sonographic signs can aid diagnosis and differentiation of simple and complicated appendicitis in children.
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Affiliation(s)
- Lauren Tong
- Department of Paediatrics, School of Clinical Sciences at Monash Health, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, VIC, Australia
| | - Ramesh M Nataraja
- Department of Paediatrics, School of Clinical Sciences at Monash Health, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, VIC, Australia
- Department of Surgery, School of Clinical Sciences at Monash Health, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, VIC, Australia
- Department of Paediatric Surgery, Monash Children's Hospital, Level 5, 246 Clayton Road, Clayton, Melbourne, VIC, 3168, Australia
| | - Keith VanHaltren
- Department of Paediatric Radiology, Monash Children's Hospital, Melbourne, VIC, Australia
| | - Tania H Sulaksana
- Department of Paediatric Surgery, Monash Children's Hospital, Level 5, 246 Clayton Road, Clayton, Melbourne, VIC, 3168, Australia
| | - Toby I Vinycomb
- Department of Paediatric Surgery, Monash Children's Hospital, Level 5, 246 Clayton Road, Clayton, Melbourne, VIC, 3168, Australia
| | - Maurizio Pacilli
- Department of Paediatrics, School of Clinical Sciences at Monash Health, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, VIC, Australia.
- Department of Surgery, School of Clinical Sciences at Monash Health, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, VIC, Australia.
- Department of Paediatric Surgery, Monash Children's Hospital, Level 5, 246 Clayton Road, Clayton, Melbourne, VIC, 3168, Australia.
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Zhou J, Xu W, Wang J, Fan Z. Related Markers for the Precision Diagnosis of Complex Appendicitis in Children. Front Pharmacol 2022; 13:865303. [PMID: 35431963 PMCID: PMC9010144 DOI: 10.3389/fphar.2022.865303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Accepted: 03/03/2022] [Indexed: 11/13/2022] Open
Abstract
Acute appendicitis is the most common surgical emergency in children. Despite the high incidence rate of appendicitis, it is sometimes misdiagnosed or missed. Complex appendicitis (CA) in children is characterized by a critical condition, several complications, and high mortality. Precision distinguishing between simple appendicitis and CA correctly is key to choosing appropriate treatment. A safe, cheap, rapid, extensive and accurate diagnostic marker of appendicitis will be of great significance for emergency general surgeons to treat suspected CA. Many studies have investigated possible diagnostic markers for the diagnosis of CA in children. In this study, studies related to CA in children in recent years are summarized, and the related markers and scoring system for the diagnosis of CA in children are summarized.
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Affiliation(s)
- Jialin Zhou
- Department of General Surgery, The Third People’s Hospital of Dalian, Dalian Medical University, Dalian, China
- Department of Central Laboratory, The Third People’s Hospital of Dalian, Dalian Medical University, Dalian, China
| | - Wenjing Xu
- Department of General Surgery, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Jitao Wang
- Department of Hepatobiliary Surgery, Xingtai People’s Hospital, Xingtai, China
- *Correspondence: Jitao Wang, ; Zhe Fan,
| | - Zhe Fan
- Department of General Surgery, The Third People’s Hospital of Dalian, Dalian Medical University, Dalian, China
- Department of Central Laboratory, The Third People’s Hospital of Dalian, Dalian Medical University, Dalian, China
- *Correspondence: Jitao Wang, ; Zhe Fan,
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3
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Lee Y, Cho H, Gwak G, Bae B, Yang K. Scoring System for Differentiation of Complicated Appendicitis in Pediatric Patients: Appendicitis Scoring System in Children. Glob Pediatr Health 2021; 8:2333794X211022268. [PMID: 34164569 PMCID: PMC8191077 DOI: 10.1177/2333794x211022268] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Accepted: 05/10/2021] [Indexed: 11/15/2022] Open
Abstract
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.
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Affiliation(s)
- Yujin Lee
- Department of General Surgery, Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Republic of Korea
| | - Hyunjin Cho
- Department of General Surgery, Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Republic of Korea
| | - Geumhee Gwak
- Department of General Surgery, Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Republic of Korea
| | - Byungnoe Bae
- Department of General Surgery, Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Republic of Korea
| | - Keunho Yang
- Department of General Surgery, Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Republic of Korea
- Keunho Yang, Department of General Surgery, Inje University Sanggye Paik Hospital, Dongil-Ro 1342, Nowon-Gu, 01757 Seoul, Republic of Korea.
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4
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Hyponatremia as a marker of complicated appendicitis: A systematic review. Surgeon 2020; 18:295-304. [PMID: 32035730 DOI: 10.1016/j.surge.2020.01.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Revised: 12/30/2019] [Accepted: 01/06/2020] [Indexed: 12/27/2022]
Abstract
BACKGROUND Acute appendicitis, the most common cause of acute surgical abdomen, is associated with intra-abdominal complications, such as perforation, that increase morbidity and mortality. Early and accurate preoperative diagnosis of complicated appendicitis mandates the identification of new diagnostic markers. This systematic review summarizes current literature on the adoption of hyponatremia as an early diagnostic and predictive marker of complicated appendicitis. METHODS Pubmed, Cochrane Library, Scopus, Google Scholar, WHO Global Health Library, System for Information on Grey Literature, ISI Web of Science, EBSCOHost and Virtual Health Library were searched in accordance with the PRISMA guidelines in order to identify original human studies investigating the association between hyponatremia and the presence or development of complicated appendicitis. RESULTS A total of 7 studies conducted in 6 different countries were identified. A prospective diagnostic accuracy study reported a strong association between hyponatremia and complicated appendicitis in children. The largest sample size study performed in adults reported a significant association between hyponatremia and perforated or gangrenous appendicitis. CONCLUSIONS The admission serum sodium level measurement, a routinely performed, low-cost test, should be taken into account in patients with clinical presentation compatible with acute appendicitis and suspicion of underlying complications. Future well-designed prospective diagnostic accuracy studies are required to further establish the association between hyponatremia and perforated appendicitis.
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Microbiota of Children With Complex Appendicitis: Different Composition and Diversity of The Microbiota in Children With Complex Compared With Simple Appendicitis. Pediatr Infect Dis J 2019; 38:1054-1060. [PMID: 31568143 DOI: 10.1097/inf.0000000000002434] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND Two types of appendicitis are hypothesized, simple and complex, with potential different treatment strategies. To improve differentiation, underlying pathogeneses need to be further unraveled. AIM To determine if the microbial composition in the appendix differs between children with simple and complex appendicitis. METHODS Two-center, prospective cohort study including 40 children (0-17 years old) undergoing appendectomy for suspected appendicitis. Appendix tissue was used for IS-pro analysis to identify bacterial species by their length of 16S-23S rDNA interspacer (IS) region. Cluster analysis, based on IS-profiles, and correspondence with type of appendicitis, using Fisher exact test, was performed. Simple and complex appendicitis were compared regarding bacterial presence, intensity and diversity, using Fisher exact test and Mann-Whitney U test, respectively. RESULTS Appendicitis was confirmed in 36 of 40 patients (16 simple, 20 complex). Cluster analysis identified 2 clusters, encompassing 34 patients. Distribution of simple and complex appendicitis was 12 (80%) and 3 (20%) versus 3 (16%) and 16 (84%) patients for clusters 1 and 2, respectively (P < 0.001). Complex appendicitis was on phylum level characterized by an increased intensity (Bacteroidetes P = 0.001, Firmicutes, Actinobacteria, Fusobacteria and Verrucomicrobia (FAFV) P = 0.005 and Proteobacteria P < 0.001) and diversity (Bacteroidetes P = 0.001 and Proteobacteria P = 0.016) and an increased abundance of 5 species (Alistipes finegoldii P = 0.009, Bacteroides fragilis P = 0.002, Escherichia coli P = 0.014, Parvimonas micra P = 0.022 and Sutterella spp P = 0.026). CONCLUSIONS The microbial composition of the appendix differs between children with simple and complex appendicitis, regarding both composition and diversity. Future research should focus on the role of these bacteria in the pathogenesis of both types and its implications for preoperative diagnostics.
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Howell EC, Dubina ED, Lee SL. Perforation risk in pediatric appendicitis: assessment and management. PEDIATRIC HEALTH MEDICINE AND THERAPEUTICS 2018; 9:135-145. [PMID: 30464677 PMCID: PMC6209076 DOI: 10.2147/phmt.s155302] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Perforated appendicitis, as defined by a visible hole in the appendix or an appendicolith free within the abdomen, carries significant morbidity in the pediatric population. Accurate diagnosis is challenging as there is no single symptom or sign that accurately predicts perforated appendicitis. Younger patients and those with increased duration of symptoms are at higher risk of perforated appendicitis. Elevated leukocytosis, bandemia, high C-reactive protein, hyponatremia, ultrasound, and CT are all useful tools in diagnosis. Distinguishing patients with perforation from those without is important given the influence of a perforation diagnosis on the management of the patient. Treatment for perforated appendicitis remains controversial as several options exist, each with its indications and merits, illustrating the complexity of this disease process. Patients may be managed non-operatively with antibiotics, with or without interval appendectomy. Patients may also undergo appendectomy early in the course of their index hospitalization. Factors known to predict failure of non-operative management include appendicolith, leukocytosis greater than 15,000 white blood cells per microliter, increased bands, and CT evidence of disease beyond the right lower quadrant. In this review, the indications and benefits of each treatment strategy will be discussed and an algorithm to guide treatment decisions will be proposed.
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Affiliation(s)
- Erin C Howell
- Department of Surgery, Harbor-UCLA Medical Center, Torrance, CA, USA,
| | - Emily D Dubina
- Department of Surgery, Harbor-UCLA Medical Center, Torrance, CA, USA,
| | - Steven L Lee
- Department of Surgery, Harbor-UCLA Medical Center, Torrance, CA, USA, .,Division of Pediatric Surgery, UCLA Mattel Children's Hospital, Los Angeles, CA, USA,
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Gorter RR, van der Lee JH, Heijsters FACJ, Cense HA, Bakx R, Kneepkens CMF, Wijnen MH, van der Steeg AFW, In't Hof KH, Offringa M, Heij HA. Outcome of initially nonoperative treatment for acute simple appendicitis in children. J Pediatr Surg 2018; 53:1849-1854. [PMID: 29395151 DOI: 10.1016/j.jpedsurg.2017.12.012] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2017] [Revised: 12/05/2017] [Accepted: 12/08/2017] [Indexed: 12/21/2022]
Abstract
PURPOSE To compare the outcome of initially nonoperative treatment with immediate appendectomy for simple appendicitis in children. METHODS Between September 2012 and June 2014 children aged 7-17 years with a radiologically confirmed simple appendicitis were invited to participate in a multicentre prospective cohort study in which they were treated with an initially nonoperative treatment strategy; nonparticipants underwent immediate appendectomy. In October 2015, their rates of complications and subsequent appendectomies, and health-related quality of life (HRQOL) were assessed. RESULTS In this period, 25 children were treated with an initially nonoperative treatment strategy and 19 with immediate appendectomy; median (range) follow-up was 25 (16-36) and 26 (17-34) months, respectively. The percentage [95%CI] of patients experiencing complications in the initially nonoperative group and the immediate appendectomy group was 12 [4-30]% and 11 [3-31]%, respectively. In total 6/25 children (24%) underwent an appendectomy; none of the 6 patients operated subsequently experienced any postappendectomy complications. Overall, HRQOL in the nonoperative treatment group was similar to that of healthy peers. CONCLUSIONS Outcome of initially nonoperative treatment for acute simple appendicitis in children is similar to the outcome in those who undergo immediate appendectomy. Initially nonoperative management seems to be able to avoid appendectomy in 3 out of 4 children. LEVEL OF EVIDENCE 2 (prospective comparative study). This research did not receive any specific grant from funding agencies in the public, commercial or not-for-profit sectors.
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Affiliation(s)
- Ramon R Gorter
- Paediatric Surgical Centre of Amsterdam. Emma Children's Hospital AMC and VU University Medical Centre, Amsterdam, the Netherlands; Department of Surgery, Red Cross Hospital. Beverwijk, the Netherlands.
| | - Johanna H van der Lee
- Paediatric Clinical Research Office, Division Woman and Child, Academic Medical Centre, Amsterdam, the Netherlands
| | - Florence A C J Heijsters
- Paediatric Surgical Centre of Amsterdam. Emma Children's Hospital AMC and VU University Medical Centre, Amsterdam, the Netherlands
| | - Huibert A Cense
- Department of Surgery, Red Cross Hospital. Beverwijk, the Netherlands
| | - Roel Bakx
- Paediatric Surgical Centre of Amsterdam. Emma Children's Hospital AMC and VU University Medical Centre, Amsterdam, the Netherlands
| | - C M Frank Kneepkens
- Department of Paediatric Gastroenterology, VU University Medical Centre, Amsterdam, the Netherlands
| | - Marc H Wijnen
- Department of Paediatric Surgery. Princess Maxima Centre, Utrecht, the Netherlands
| | - Alida F W van der Steeg
- Paediatric Surgical Centre of Amsterdam. Emma Children's Hospital AMC and VU University Medical Centre, Amsterdam, the Netherlands; Centre of Research on Psychology in Somatic Disease (CoRPS), Tilburg University, the Netherlands
| | | | - Martin Offringa
- Child Health Evaluation Sciences (CHES), The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Hugo A Heij
- Paediatric Surgical Centre of Amsterdam. Emma Children's Hospital AMC and VU University Medical Centre, Amsterdam, the Netherlands
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Yoon HM, Kim JH, Lee JS, Ryu JM, Kim DY, Lee JY. Pediatric appendicitis with appendicolith often presents with prolonged abdominal pain and a high risk of perforation. World J Pediatr 2018; 14:184-190. [PMID: 29508363 DOI: 10.1007/s12519-018-0128-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Revised: 03/04/2017] [Accepted: 03/05/2017] [Indexed: 12/29/2022]
Abstract
BACKGROUND Appendicolith can cause appendiceal obstruction and acute appendicitis. Its high prevalence may be related to the high perforation rate in pediatric appendicitis. This study assessed the characteristics of appendicolith and its clinical significance in pediatric appendicitis. METHODS A retrospective study was performed among children and adolescents younger than 17 years who were preoperatively diagnosed with appendicitis in the pediatric emergency department (ED). A total of 269 patients with a mean age of 9.98 ± 3.37 years were enrolled. Clinical features and contrast-enhanced computed tomography findings were analyzed. RESULTS Among the 269 patients, 147 (54.6%) had appendicoliths, with a mean maximal diameter of 5.21 ± 2.34 mm. Compared to the no appendicolith group, the appendicolith group demonstrated more prolonged abdominal pain (≥ 48 hours) before the ED visit (23.1% vs. 11.5%; P = 0.013), clinical features of severe appendicitis (presence of fever, vomiting, positive urine ketone, and increased C-reactive protein), and higher rate of perforation (43.5% vs. 9.8%; P < 0.001). Multivariate risk factor analysis for perforated appendicitis in the appendicolith group revealed that maximal diameter of 5 mm or more in the appendicolith (adjusted odds ratio [aOR] 2.919; 95% CI 1.325-6.428, P = 0.008) and proximal collapse adjacent to the appendicolith (aOR 2.943; 95% CI 1.344-6.443, P = 0.007) were significant. CONCLUSIONS Pediatric appendicitis with appendicolith often presents with prolonged abdominal pain and severe clinical conditions with a high risk of perforation.
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Affiliation(s)
- Hee Mang Yoon
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, 05505, South Korea
| | - Jung Heon Kim
- Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, 05505, South Korea
| | - Jong Seung Lee
- Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, 05505, South Korea
| | - Jeong-Min Ryu
- Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, 05505, South Korea
| | - Dae Yeon Kim
- Department of Pediatric Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, 05505, South Korea
| | - Jeong-Yong Lee
- Department of Pediatrics, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, South Korea.
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Bonadio W, Shahid S, Vardi L, Buckingham C, Kornblatt A, Free C, Homel P. A pre-operative clinical scoring system to distinguish perforation risk with pediatric appendicitis. J Pediatr Surg 2018; 53:441-445. [PMID: 28554816 DOI: 10.1016/j.jpedsurg.2017.05.017] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Revised: 05/05/2017] [Accepted: 05/16/2017] [Indexed: 12/12/2022]
Abstract
IMPORTANCE Appendicitis is a common, potentially serious pediatric disease. An important factor in determining management strategy [whether/when to perform appendectomy, duration of antibiotic therapy/hospitalization, etc.] and predicting outcome is distinguishing whether perforation is present. OBJECTIVE The objective was to determine efficacy of commonly assessed pre-operative variables in stratifying perforation risk in children with appendicitis. DESIGN A retrospective analysis of consecutive cases was performed. SETTING The setting was a large urban hospital pediatric emergency department. PARTICIPANTS Four hundred forty-eight consecutive cases of CT [computerized tomography]-confirmed pediatric appendicitis during a 6-year period in an urban pediatric ED [emergency department]: 162 with perforation and 286 non-perforated. MAIN OUTCOME(S) AND MEASURE(S) To determine efficacy of clinical and laboratory variables with distinguishing perforation outcome in children with appendicitis. RESULTS Regression analysis identified 3 independently significant variables associated with perforation outcome - and determined their ideal threshold values: duration of symptoms>1day; ED-measured fever [body temperature >38.0 °C]; CBC WBC absolute neutrophil count >13,000/mm3. The resulting multivariate ROC [receiver operating characteristic] curve after applying these threshold values gave an AUC [area under curve] of 89% for perforation outcome [p<0.001]. Risk for perforation was additive with each additional predictive variable exceeding its threshold value, linearly increasing from 7% with no variable present to 85% when all 3 variables are present. CONCLUSIONS A pre-operative scoring system comprised of 3 commonly assessed clinical/laboratory variables is useful in stratifying perforation risk in children with appendicitis. Physicians can utilize these factors to gauge pre-operative risk for perforation in children with appendicitis, which can potentially aid in planning subsequent management strategy. LEVEL OF EVIDENCE III.
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Affiliation(s)
- William Bonadio
- Pediatric Emergency Medicine, Maimonides Medical Center, Brooklyn, NY.
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Blumfield E, Yang D, Grossman J. Scoring system for differentiating perforated and non-perforated pediatric appendicitis. Emerg Radiol 2017; 24:547-554. [PMID: 28685263 DOI: 10.1007/s10140-017-1535-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2017] [Accepted: 06/21/2017] [Indexed: 12/26/2022]
Abstract
OBJECTIVES Appendicitis is the most common indication for emergency pediatric surgery and its most significant complication is perforation. Perforated appendicitis (PA) may be managed conservatively, whereas non-perforated appendicitis (NP) is managed surgically. Recent studies have shown that ultrasound (US) is effective for differentiating between PA and NP, and does not expose pediatric patients to ionizing radiation. The purpose of this study is to enhance the accuracy of differentiation with a novel scoring system based on clinical, laboratory, and US findings. METHODS This retrospective study included 243 patients aged 2-17 years who presented between 2006 and 2013 with surgically proven appendicitis, of whom 60 had perforation. Clinical and laboratory data were collected and US images evaluated by a pediatric radiologist. To create the scoring system, point values were assigned to each parameter. A randomly selected training sample of 137 subjects was used to create a scoring prediction model. The model was tested on the remaining 106 patients. RESULTS Scores of ≥6, ≥11, and ≥15 yielded specificities of 64, 91, and 99%, and sensitivities of 96, 61, and 29%, respectively (p < 0.001). CONCLUSIONS We have designed a scoring system incorporating clinical, laboratory, and sonographic findings which can differentiate PA from NP with high specificity.
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Affiliation(s)
- Einat Blumfield
- Department of Radiology, Albert Einstein College of Medicine/Jacobi Medical Center, 1400 Pelham Parkway South, Bronx, NY, USA
| | - Daniel Yang
- Department of Radiology, Albert Einstein College of Medicine/Jacobi Medical Center, 1400 Pelham Parkway South, Bronx, NY, USA.
| | - Joshua Grossman
- Department of Pediatrics, Albert Einstein College of Medicine/Montefiore Medical Center, 111 East 210th Street, Bronx, NY, USA
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Benabbas R, Hanna M, Shah J, Sinert R. Diagnostic Accuracy of History, Physical Examination, Laboratory Tests, and Point-of-care Ultrasound for Pediatric Acute Appendicitis in the Emergency Department: A Systematic Review and Meta-analysis. Acad Emerg Med 2017; 24:523-551. [PMID: 28214369 DOI: 10.1111/acem.13181] [Citation(s) in RCA: 100] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2016] [Revised: 01/17/2017] [Accepted: 02/06/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND Acute appendicitis (AA) is the most common surgical emergency in children. Accurate and timely diagnosis is crucial but challenging due to atypical presentations and the inherent difficulty of obtaining a reliable history and physical examination in younger children. OBJECTIVES The aim of this study was to determine the utility of history, physical examination, laboratory tests, Pediatric Appendicitis Score (PAS) and Emergency Department Point-of-Care Ultrasound (ED-POCUS) in the diagnosis of AA in ED pediatric patients. We performed a systematic review and meta-analysis and used a test-treatment threshold model to identify diagnostic findings that could rule in/out AA and obviate the need for further imaging studies, specifically computed tomography (CT) scan, magnetic resonance imaging (MRI), and radiology department ultrasound (RUS). METHODS We searched PubMed, EMBASE, and SCOPUS up to October 2016 for studies on ED pediatric patients with abdominal pain. Quality Assessment Tool for Diagnostic Accuracy Studies (QUADAS-2) was used to evaluate the quality and applicability of included studies. Positive and negative likelihood ratios (LR+ and LR-) for diagnostic modalities were calculated and when appropriate data was pooled using Meta-DiSc. Based on the available literature on the test characteristics of different imaging modalities and applying the Pauker-Kassirer method we developed a test-treatment threshold model. RESULTS Twenty-one studies were included encompassing 8,605 patients with weighted AA prevalence of 39.2%. Studies had variable quality using the QUADAS-2 tool with most studies at high risk of partial verification bias. We divided studies based on their inclusion criteria into two groups of "undifferentiated abdominal pain" and abdominal pain "suspected of AA." In patients with undifferentiated abdominal pain, history of "pain migration to right lower quadrant (RLQ)" (LR+ = 4.81, 95% confidence interval [CI] = 3.59-6.44) and presence of "cough/hop pain" in the physical examination (LR+ = 7.64, 95% CI = 5.94-9.83) were most strongly associated with AA. In patients suspected of AA none of the history or laboratory findings were strongly associated with AA. Rovsing's sign was the physical examination finding most strongly associated with AA (LR+ = 3.52, 95% CI = 2.65-4.68). Among different PAS cutoff points, PAS ≥ 9 (LR+ = 5.26, 95% CI = 3.34-8.29) was most associated with AA. None of the history, physical examination, laboratory tests findings, or PAS alone could rule in or rule out AA in patients with undifferentiated abdominal pain or those suspected of AA. ED-POCUS had LR+ of 9.24 (95% CI = 6.24-13.28) and LR- of 0.17 (95% CI = 0.09-0.30). Using our test-treatment threshold model, positive ED-POCUS could rule in AA without the use of CT and MRI, but negative ED-POCUS could not rule out AA. CONCLUSION Presence of AA is more likely in patients with undifferentiated abdominal pain migrating to the RLQ or when cough/hop pain is present in the physical examination. Once AA is suspected, no single history, physical examination, laboratory finding, or score attained on PAS can eliminate the need for imaging studies. Operating characteristics of ED-POCUS are similar to those reported for RUS in literature for diagnosis of AA. In ED patients suspected of AA, a positive ED-POCUS is diagnostic and obviates the need for CT or MRI while negative ED-POCUS is not enough to rule out AA.
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Affiliation(s)
- Roshanak Benabbas
- Department of Emergency Medicine; State University of New York/SUNY Downstate Medical Center; Brooklyn NY
- Department of Emergency Medicine; Kings County Hospital Center; Brooklyn NY
| | - Mark Hanna
- Department of Pediatrics; State University of New York/SUNY Downstate Medical Center; Brooklyn NY
- Department of Pediatrics; Kings County Hospital Center; Brooklyn NY
| | - Jay Shah
- Department of Emergency Medicine; Kings County Hospital Center; Brooklyn NY
| | - Richard Sinert
- Department of Emergency Medicine; State University of New York/SUNY Downstate Medical Center; Brooklyn NY
- Department of Emergency Medicine; Kings County Hospital Center; Brooklyn NY
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12
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Appendicitis in preschool aged children: Regression analysis of factors associated with perforation outcome. J Pediatr Surg 2015; 50:1569-73. [PMID: 25783356 DOI: 10.1016/j.jpedsurg.2015.02.050] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2014] [Revised: 02/09/2015] [Accepted: 02/14/2015] [Indexed: 11/21/2022]
Abstract
OBJECTIVES Apply multivariate regression analysis to determine the significance of clinical variables for perforation outcome of a large series of preschool aged children with appendicitis. METHODS Retrospective case review of 180 consecutive children<5 years of age diagnosed with appendicitis during an 8-year period. RESULTS This age group accounted for only 9% of all cases of pediatric appendicitis at our institution during the study period. Perforation rate was inversely proportional to patient age, occurring in 100% aged<1 year, 91% ages 1-2 years, 76% ages 2-3 years, 73% ages 3-4 years, and 57% ages 4-5 years. Risk for perforation increased proportionately with duration of symptoms, ranging from 48% when<1 day vs 84% when>1 day; and 93% when>2 days. One-quarter with perforation had a prior recent medical evaluation with an alternative diagnosis rendered preappendicitis diagnosis. The mean duration of hospitalization was four times longer in those with perforation [8 days] vs no perforation [2 days]. Univariate analysis showed each of the following factors was significantly associated with perforation outcome: younger patient age, female gender, prior medical visit<48 hours of appendicitis diagnosis, symptom duration, presence of fever, and presence of appendicolith. Multivariate logistic regression combining all significant univariate predictors showed only duration of symptoms and presence of appendicolith were significantly associated with perforation outcome; receiver-operating characteristic curves are generated to evaluate the predictive accuracy of these two factors, both individually and when combined. CONCLUSIONS Although relatively uncommon in this age group, appendicitis is frequently associated with delayed diagnosis and perforation outcome. Risk for perforation is directly proportional to increasing duration of symptoms. Clinicians must maintain a high index of suspicion for this condition in these younger children, as early diagnosis is essential to maximizing outcome.
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13
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Gorter RR, van den Boom AL, Heij HA, Kneepkens CMF, Hulsker CC, Tenhagen M, Dawson I, van der Lee JH. A scoring system to predict the severity of appendicitis in children. J Surg Res 2015; 200:452-9. [PMID: 26434504 DOI: 10.1016/j.jss.2015.08.042] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2015] [Revised: 07/24/2015] [Accepted: 08/21/2015] [Indexed: 12/26/2022]
Abstract
BACKGROUND It appears that two forms of appendicitis exist. Preoperative distinction between the two is essential to optimize treatment outcome. This study aimed to develop a scoring system to accurately determine the severity of appendicitis in children. MATERIALS AND METHODS Historical cohort study of pediatric patients (aged 0-17 y old) with appendicitis treated between January 2010 and December 2012. Division into simple, complex appendicitis, or another condition based on preset criteria. Multiple logistic regression analysis was used to build the prediction model with subsequent validation. RESULTS There were 64 patients with simple and 66 with complex appendicitis. Five variables explained 64% of the variation. Independent validation of the derived prediction model in a second cohort (55 simple and 10 complex appendicitis patients) demonstrated 90% sensitivity (54-99), 91% specificity (79-97), a positive predictive value of 64% (36-86), and an negative predictive value of 98% (88-100). The likelihood ratio+ was 10 (4.19-23.42), and likelihood ratio- was 0.11 (0.02-0.71). Diagnostic accuracy was 91% (84-98). CONCLUSIONS Our scoring system consisting of five variables can be used to exclude complex appendicitis in clinical practice if the score is <4.
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Affiliation(s)
- Ramon R Gorter
- Department of Paediatric Surgery, Paediatric Surgical Centre of Amsterdam, Emma Children's Hospital AMC & VU University Medical Centre, Amsterdam, The Netherlands; Department of Surgery, Red Cross Hospital, Beverwijk, The Netherlands.
| | | | - Hugo A Heij
- Department of Paediatric Surgery, Paediatric Surgical Centre of Amsterdam, Emma Children's Hospital AMC & VU University Medical Centre, Amsterdam, The Netherlands
| | - C M Frank Kneepkens
- Department of Paediatric Gastroenterology, VU University Medical Centre, Amsterdam, The Netherlands
| | - Caroline C Hulsker
- Department of Paediatric Surgery, Paediatric Surgical Centre of Amsterdam, Emma Children's Hospital AMC & VU University Medical Centre, Amsterdam, The Netherlands
| | - Mark Tenhagen
- Department of Surgery, Red Cross Hospital, Beverwijk, The Netherlands
| | - Imro Dawson
- Department of Surgery, IJsselland Hospital, Capelle aan Den IJssel, The Netherlands
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14
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Gorter RR, van der Lee JH, Cense HA, Kneepkens CMF, Wijnen MHWA, In 't Hof KH, Offringa M, Heij HA. Initial antibiotic treatment for acute simple appendicitis in children is safe: Short-term results from a multicenter, prospective cohort study. Surgery 2015; 157:916-23. [PMID: 25791031 DOI: 10.1016/j.surg.2015.01.008] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2014] [Revised: 12/30/2014] [Accepted: 01/11/2015] [Indexed: 12/26/2022]
Abstract
BACKGROUND Initial antibiotic treatment for acute appendicitis has been shown to be safe in adults; so far, not much is known about the safety and efficacy of this treatment in children. The aims of this study were to investigate the feasibility of a randomized controlled trial (RCT) evaluating initial antibiotic treatment for acute appendectomy in children with acute simple appendicitis and to evaluate the safety of this approach. METHODS In a multicenter, prospective cohort study patients aged 7-17 years with a radiologically confirmed simple appendicitis were eligible. Intravenous antibiotics (amoxicillin/clavulanic acid 250/25 mg/kg 4 times daily; maximum 6,000/600 mg/d and gentamicin 7 mg/kg once daily) were administered for 48-72 hours. Clinical reevaluation every 6 hours, daily blood samples, and ultrasound follow-up after 48 hours was performed. In case of improvement after 48 hours, oral antibiotics were given for a total of 7 days. At any time, in case of clinical deterioration or non-improvement after 72 hours, an appendectomy could be performed. Follow-up continued until 8 weeks after discharge. Adverse events were defined as major complications of antibiotic treatment, such as allergic reactions, perforated appendicitis, and recurrent appendicitis. RESULTS Of 44 eligible patients, 25 participated (inclusion rate, 57%; 95% CI, 42%-70%). Delayed appendectomy was performed in 2, and the other 23 were without symptoms at the 8 weeks follow-up. Minor complications occurred in three patients. None of the patients suffered from an adverse event or a recurrent appendicitis. CONCLUSION Our study shows that an RCT comparing initial antibiotic treatment strategy with urgent appendectomy is feasible in children; the intervention seems to be safe.
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Affiliation(s)
- Ramon R Gorter
- Paediatric Surgical Centre of Amsterdam, Emma Children's Hospital AMC & VU University Medical Centre, Amsterdam, The Netherlands; Department of Surgery, Red Cross Hospital, Beverwijk, The Netherlands.
| | - Johanna H van der Lee
- Paediatric Clinical Research Office Division Woman and Child, Academic Medical Centre, Amsterdam, The Netherlands
| | - Huibert A Cense
- Department of Surgery, Red Cross Hospital, Beverwijk, The Netherlands
| | - C M Frank Kneepkens
- Department of Paediatric Gastroenterology, VU University Medical Centre, Amsterdam, The Netherlands
| | - Marc H W A Wijnen
- Department of Paediatric Surgery, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | | | - Martin Offringa
- Child Health Evaluative Sciences (CHES), The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Hugo A Heij
- Paediatric Surgical Centre of Amsterdam, Emma Children's Hospital AMC & VU University Medical Centre, Amsterdam, The Netherlands
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15
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Abstract
We present the case of an 8-year-old girl with two emergency department visits for constipation and abdominal pain. Her medical history and physical examination noted by the emergency physician did not reveal a clear etiology of her symptoms until the second visit, when a point-of-care ultrasound was performed. The sonographic findings were consistent with a fecalith surrounded by fluid concerning for appendiceal rupture. A computerized tomographic scan of the abdomen confirmed these findings in addition to two large abscesses in the lower pelvis, which subsequently required percutaneous drainage. This case illustrates the utility of point-of-care ultrasound in the evaluation of the pediatric patient with abdominal pain when appendicitis is a concern, as well as the ability of the emergency physician to use this technology to guide treatment and care of pediatric patients.
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16
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Mathews EK, Griffin RL, Mortellaro V, Beierle EA, Harmon CM, Chen MK, Russell RT. Utility of immature granulocyte percentage in pediatric appendicitis. J Surg Res 2014; 190:230-4. [PMID: 24793450 DOI: 10.1016/j.jss.2014.04.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2014] [Revised: 03/23/2014] [Accepted: 04/03/2014] [Indexed: 11/17/2022]
Abstract
BACKGROUND Acute appendicitis is the most common cause of abdominal surgery in children. Adjuncts are used to help clinicians predict acute or perforated appendicitis, which may affect treatment decisions. Automated hematologic analyzers can perform more accurate automated differentials including immature granulocyte percentages (IG%). Elevated IG% has demonstrated improved accuracy for predicting sepsis in the neonatal population than traditional immature-to-total neutrophil count ratios. We intended to assess the additional discriminatory ability of IG% to traditionally assessed parameters in the differentiation between acute and perforated appendicitis. MATERIALS AND METHODS We identified all patients with appendicitis from July 2012-June 2013 by International Classification of Diseases-9 code. Charts were reviewed for relevant demographic, clinical, and outcome data, which were compared between acute and perforated appendicitis groups using Fisher exact and t-tests for categorical and continuous variables, respectively. We used an adjusted logistic regression model using clinical laboratory values to predict the odds of perforated appendicitis. RESULTS A total of 251 patients were included in the analysis. Those with perforated appendicitis had a higher white blood cell count (P=0.0063), C-reactive protein (CRP) (P<0.0001), and IG% (P=0.0299). In the adjusted model, only elevated CRP (odds ratio 3.46, 95% confidence interval 1.40-8.54) and presence of left shift (odds ratio 2.66, 95% confidence interval 1.09-6.46) were significant predictors of perforated appendicitis. The c-statistic of the final model was 0.70, suggesting fair discriminatory ability in predicting perforated appendicitis. CONCLUSIONS IG% did not provide any additional benefit to elevated CRP and presence of left shift in the differentiation between acute and perforated appendicitis.
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Affiliation(s)
- Eleanor K Mathews
- Department of Pediatric Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Russell L Griffin
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Vincent Mortellaro
- Department of Pediatric Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Elizabeth A Beierle
- Department of Pediatric Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Carroll M Harmon
- Department of Pediatric Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Mike K Chen
- Department of Pediatric Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Robert T Russell
- Department of Pediatric Surgery, University of Alabama at Birmingham, Birmingham, Alabama.
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17
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Nazarey PP, Stylianos S, Velis E, Triana J, Diana-Zerpa J, Pasaron R, Stylianos V, Malvezzi L, Knight C, Burnweit C. Treatment of suspected acute perforated appendicitis with antibiotics and interval appendectomy. J Pediatr Surg 2014; 49:447-50. [PMID: 24650475 DOI: 10.1016/j.jpedsurg.2013.10.001] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2012] [Revised: 10/03/2013] [Accepted: 10/04/2013] [Indexed: 12/13/2022]
Abstract
BACKGROUND Initial antibiotics with planned interval appendectomy (interval AP) have been used to treat patients with complicated perforated appendicitis; however, little experience exists with this approach in children with suspected acute perforated appendicitis (SAPA). We sought to determine the outcome of initial antibiotics and interval AP in children with SAPA. METHODS Over an 18-month period, 751 consecutive patients underwent appendectomy including 105 patients with SAPA who were treated with initial intravenous antibiotics and planned interval AP ≥ 8 weeks after presentation. All SAPA patients had symptoms for ≤ 96 hours. Primary outcome variables were rates of readmission, abscess formation, and need for interval AP prior to the planned ≥ 8 weeks. RESULTS Intraabdominal abscess rate was 27%. Appendectomy prior to planned interval AP was 11% and readmission occurred in 34%. All patients underwent eventual appendectomy with pathologic confirmation confirming the previous appendiceal inflammation. White blood cell (WBC) count >15,000, WBC >15,000 plus fecalith on imaging, and WBC >15,000 plus duration of symptoms >48 hours were all significantly associated with higher rates of readmission (p=0.01, p=0.04, p=0.02) and need for interval AP prior to the planned ≥ 8 weeks (p=0.003, p=0.05, p=0.03). CONCLUSIONS Treatment of SAPA with antibiotics and planned interval AP is successful in the majority of patients; however, complications such as abscess formation and/or readmission prior to planned interval AP occur in up to one-third of patients. Certain clinical variables are associated with increased treatment complications.
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Affiliation(s)
- Pradeep P Nazarey
- Department of Pediatric Surgery, Miami Children's Hospital, Miami, FL, USA.
| | - Steven Stylianos
- Department of Pediatric Surgery, Miami Children's Hospital, Miami, FL, USA; FIU College of Medicine, Miami, FL, USA
| | - Evelio Velis
- College of Health Sciences, Barry University, Miami, FL, USA
| | - Jason Triana
- Department of Pediatric Surgery, Miami Children's Hospital, Miami, FL, USA
| | | | - Raquel Pasaron
- Department of Pediatric Surgery, Miami Children's Hospital, Miami, FL, USA
| | - Vanessa Stylianos
- Department of Pediatric Surgery, Miami Children's Hospital, Miami, FL, USA
| | - Leopoldo Malvezzi
- Department of Pediatric Surgery, Miami Children's Hospital, Miami, FL, USA
| | - Colin Knight
- Department of Pediatric Surgery, Miami Children's Hospital, Miami, FL, USA
| | - Cathy Burnweit
- Department of Pediatric Surgery, Miami Children's Hospital, Miami, FL, USA
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Antibiotic administration can be an independent risk factor for therapeutic delay of pediatric acute appendicitis. Pediatr Emerg Care 2012; 28:792-5. [PMID: 22858754 DOI: 10.1097/pec.0b013e3182628810] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Little is known about the relationship between prior treatment with antibiotics and delay of diagnosis and treatment in pediatric acute appendicitis (AA). We have defined a situation requiring more than 48 hours from the onset of symptoms to surgery in pediatric AA as "therapeutic delay." The aim of this study was to investigate the risk factors contributing to therapeutic delay in pediatric AA. METHODS We conducted a retrospective chart review of AA children operated on between 2003 and 2008 at tertiary-care pediatric and perinatal hospitals. Univariate and multivariate logistic regressions were analyzed to determine independent risk factors of therapeutic delay in pediatric AA. RESULTS The duration between the onset of symptoms and surgery was more than 48 hours (therapeutic delay) in 50 patients (25%, group A) and 48 hours or less in 151 patients (75%, group B). The patients in group A had a significantly higher frequency of diarrhea (48% vs 12%; P < 0.0001). The percentages of children who had previously received antibiotics were more frequent in group A (46% vs 8%; P < 0.0001). The median C-reactive protein levels (72 vs 7 mg/L; P < 0.0001) and frequency of perforation (60% vs 13%; P < 0.0001) were statistically significantly higher in group A. A multivariate analysis demonstrated that the independent risk factors of therapeutic delay were history of receiving antibiotics (odds ratio [OR], 5.8; 95% confidence interval [CI], 2.3-15.5), diarrhea (OR, 5.2; 95% CI, 2.1-13.1), and elevated C-reactive protein levels (OR, 4.5; 95% CI, 1.9-10.8). CONCLUSIONS Prior treatment with antibiotics was an independent risk factor for therapeutic delay in pediatric AA.
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Gosain A, Williams RF, Blakely ML. Distinguishing acute from ruptured appendicitis preoperatively in the pediatric patient. Adv Surg 2010; 44:73-85. [PMID: 20919515 DOI: 10.1016/j.yasu.2010.05.021] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Affiliation(s)
- Ankush Gosain
- Division of Pediatric Surgery, Department of Surgery, University of Tennessee Health Sciences Center, 777 Washington Avenue, Suite P220, Memphis, TN 38105, USA
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20
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Williams RF, Blakely ML, Fischer PE, Streck CJ, Dassinger MS, Gupta H, Renaud EJ, Eubanks JW, Huang EY, Hixson SD, Langham MR. Diagnosing Ruptured Appendicitis Preoperatively in Pediatric Patients. J Am Coll Surg 2009; 208:819-25; discussion 826-8. [DOI: 10.1016/j.jamcollsurg.2009.01.029] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2008] [Accepted: 01/14/2009] [Indexed: 10/21/2022]
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