1
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Theilen TM, Rolle U. [The acute abdomen in children]. Med Klin Intensivmed Notfmed 2023; 118:619-625. [PMID: 37294351 PMCID: PMC10252174 DOI: 10.1007/s00063-023-01030-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 05/03/2023] [Indexed: 06/10/2023]
Abstract
BACKGROUND Because 8-10% of children in the emergency room present with acute abdominal pain, a systematic work-up is essential to rule out acute abdomen. OBJECTIVES This article highlights the etiology, symptoms, diagnostic workup, and treatment of acute abdomen in children. MATERIALS AND METHODS Review of the current literature. RESULTS Abdominal inflammation, ischemia, bowel and ureteral obstruction, or abdominal bleeding are causes of acute abdomen. Extra-abdominal diseases such as otitis media in toddlers or testicular torsion in adolescent boys can also lead to symptoms of acute abdomen. Abdominal pain, (bilious) vomiting, abdominal guarding, constipation, blood-tinged stools, abdominal bruise marks, and poor condition of the patient with symptoms such as tachycardia, tachypnea, and hypotonia up to shock are leading symptoms of acute abdomen. In some cases, emergent abdominal surgery is needed to treat the cause of the acute abdomen. However, in patients with pediatric inflammatory multisystem syndrome temporarily associated with SARS-CoV‑2 infection (PIMS-TS), a new disease causing an acute abdomen, surgical treatment is rarely needed. CONCLUSIONS Acute abdomen can lead to nonreversible loss of an abdominal organ, such as bowel or ovary, or develop into acute deterioration of the patient's condition up to the state of shock. Therefore, a complete history and thorough physical examination are needed to timely diagnose acute abdomen and initiate specific therapy.
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Affiliation(s)
- Till-Martin Theilen
- Klinik für Kinderchirurgie und Kinderurologie, Universitätsklinikum Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Deutschland
| | - Udo Rolle
- Klinik für Kinderchirurgie und Kinderurologie, Universitätsklinikum Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Deutschland.
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2
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Ardicli B, User IR, Tigli T, Ozcan HN, Oguz B, Haliloglu M, Kesici S, Ozsurekci Y, Cengiz AB, Ceyhan M, Ertugrul I, Ekinci S. Favourable outcomes of conservatively managed acute abdomen associated with multisystem inflammatory syndrome in children during the COVID-19 pandemic. ANZ J Surg 2023; 93:108-114. [PMID: 36409168 DOI: 10.1111/ans.18162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 07/26/2022] [Accepted: 11/05/2022] [Indexed: 11/23/2022]
Abstract
BACKGROUNDS Abdominal pain is one of the most common symptoms of multisystem inflammatory syndrome in children (MIS-C). Abdominal pain can vary from mild to severe and may present as acute abdomen. Severe abdominal pain in patients with MIS-C should be differentiated from surgical causes of acute abdomen to prevent unnecessary surgery. METHODS The diagnosis of MIS-C was based on WHO and CDC recommended criteria. Records of children treated for MIS-C between September 2020 and January 2021 were reviewed retrospectively. RESULTS In a short time, we encountered seven patients who were diagnosed with MIS-C and showed acute abdomen findings. There were four male and three female patients. The median age was 9 years. Fever, abdominal pain and distension were present in all. The median duration of symptoms was 4 days. Five patients had general abdominal tenderness mimicking acute abdomen. Three patients had right lower quadrant tenderness mimicking acute appendicitis. After the initiation of immunomodulatory therapy and antibiotics, the physical examination findings were improved step by step in all. The median time to initiate oral feeding was 2 days. The median length of hospitalization time was 8 days. CONCLUSION Serial abdominal examinations performed by the same surgeon enabled us to follow these patients conservatively and thus avoid unnecessary surgical intervention.
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Affiliation(s)
- Burak Ardicli
- Department of Medical and Surgical Research, Hacettepe University, Institute of Health Sciences, Ankara, Turkey.,Faculty of Medicine, Department of Paediatric Surgery, Hacettepe University, Ankara, Turkey
| | - Idil Rana User
- Department of Medical and Surgical Research, Hacettepe University, Institute of Health Sciences, Ankara, Turkey.,Faculty of Medicine, Department of Paediatric Surgery, Hacettepe University, Ankara, Turkey
| | - Tunc Tigli
- Faculty of Medicine, Department of Paediatric Surgery, Hacettepe University, Ankara, Turkey
| | - H Nursun Ozcan
- Faculty of Medicine, Department of Radiology, Division of Paediatric Radiology, Hacettepe University, Ankara, Turkey
| | - Berna Oguz
- Faculty of Medicine, Department of Radiology, Division of Paediatric Radiology, Hacettepe University, Ankara, Turkey
| | - Mithat Haliloglu
- Faculty of Medicine, Department of Radiology, Division of Paediatric Radiology, Hacettepe University, Ankara, Turkey
| | - Selman Kesici
- Faculty of Medicine, Department of Paediatrics, Division of Intensive Care Unit, Hacettepe University, Ankara, Turkey
| | - Yasemin Ozsurekci
- Faculty of Medicine, Department of Paediatrics, Division of Paediatric Infectious Diseases, Hacettepe University, Ankara, Turkey
| | - Ali Bulent Cengiz
- Faculty of Medicine, Department of Paediatrics, Division of Paediatric Infectious Diseases, Hacettepe University, Ankara, Turkey
| | - Mehmet Ceyhan
- Faculty of Medicine, Department of Paediatrics, Division of Paediatric Infectious Diseases, Hacettepe University, Ankara, Turkey
| | - Ilker Ertugrul
- Faculty of Medicine, Department of Paediatrics, Division of Paediatric Cardiology, Hacettepe University, Ankara, Turkey
| | - Saniye Ekinci
- Department of Medical and Surgical Research, Hacettepe University, Institute of Health Sciences, Ankara, Turkey.,Faculty of Medicine, Department of Paediatric Surgery, Hacettepe University, Ankara, Turkey
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3
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del Giorgio F, Habti M, Merckx J, Kaufman JS, Gravel J, Piché N, Osmanlliu E, Drouin O. Investigating changes in incidence and severity of pediatric appendicitis during the COVID-19 pandemic in Canada: an interrupted time series analysis. World J Pediatr 2023; 19:288-292. [PMID: 36574211 PMCID: PMC9792923 DOI: 10.1007/s12519-022-00656-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Accepted: 11/16/2022] [Indexed: 12/28/2022]
Affiliation(s)
- Francesca del Giorgio
- grid.14709.3b0000 0004 1936 8649Department of Epidemiology and Biostatistics, McGill University, Montreal, Canada
| | - Merieme Habti
- grid.14848.310000 0001 2292 3357Present Address: Department of Medicine, Université de Montréal, Montreal, Canada
| | - Joanna Merckx
- grid.14709.3b0000 0004 1936 8649Department of Epidemiology and Biostatistics, McGill University, Montreal, Canada
| | - Jay S. Kaufman
- grid.14709.3b0000 0004 1936 8649Department of Epidemiology and Biostatistics, McGill University, Montreal, Canada
| | - Jocelyn Gravel
- grid.411418.90000 0001 2173 6322Department of Pediatric Emergency Medicine, Centre Hospitalier Universitaire Sainte-Justine, Montreal, Canada
| | - Nelson Piché
- grid.411418.90000 0001 2173 6322Department of Pediatric Surgery, Centre Hospitalier Universitaire Sainte-Justine, Montreal, Canada
| | - Esli Osmanlliu
- grid.416084.f0000 0001 0350 814XDivision of Pediatric Emergency Surgery, Montreal Children’s Hospital, Montreal, Canada
| | - Olivier Drouin
- Department of Social and Preventative Medicine, Université de Montréal, Montreal, Canada. .,Department of Pediatrics, Centre Hospitalier Universitaire Sainte-Justine, Montreal, Canada.
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4
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Ayyıldız HN, Mirapoglu S, Yıldız ZA, Şahin C, Güvenç FT, Arpacık M, İlce Z. What has changed in children's appendicitis during the COVID-19 pandemic? ULUS TRAVMA ACIL CER 2022; 28:1674-1681. [PMID: 36453784 PMCID: PMC10198316 DOI: 10.14744/tjtes.2021.51000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2021] [Accepted: 11/12/2021] [Indexed: 06/04/2023]
Abstract
BACKGROUND The present study aimed to investigate the changes in the course of acute appendicitis during the pandemic period by comparing the cases treated during the coronavirus disease 2019 (COVID-19) pandemic with those in the pre-pandemic period. METHODS The study was conducted with 601 children aged 1-18 years who were operated for acute appendicitis between May 1, 2019, and February 29, 2020 (Group I) and between March 1 and December 31, 2020 (Group II). The demographic and disease characteristics as well as the treatment processes were compared between the groups. RESULTS It was found that 59.1% (n=355) of the cases included in the study were in Group I and 40.9% (n=246) were in Group II. During the pandemic period; due to the concerns of families about contracting a contagious disease for both themselves and their children, and warnings by health professionals and government officials that they should not leave their homes and not come to the hospital unless there is an emergency, the time to apply to the hospital has been extended. Before the pandemic, 20.3% of the patients presented to the hospital on the 1st day of their complaints, where during the pandemic, only 2% of the patients reported to the hospital on the 1st day, and 15% presented after 4 days or more. As a result, the rate of perforated appendicitis, which was formerly 10.4%, increased to 24.8% during the pandemic period (p<0.01). During the pandemic, we operated on four patients with positive COVID-19 test results. There were no complications related to COVID-19 and surgery in our patients. CONCLUSION Concern of the current pandemic resulted in late presentation to the hospital, increase in the number of perforated appendicitis, and prolonged hospital stay.
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Affiliation(s)
- Hayriye Nihan Ayyıldız
- Department of Pediatric Surgery, University of Health Sciences, Ümraniye Training and Research Hospital, İstanbul-Türkiye
| | - Semih Mirapoglu
- Department of Pediatric Surgery, University of Health Sciences, Ümraniye Training and Research Hospital, İstanbul-Türkiye
| | - Zeliha Akış Yıldız
- Department of Pediatric Surgery, University of Health Sciences, Ümraniye Training and Research Hospital, İstanbul-Türkiye
| | - Ceyhan Şahin
- Department of Pediatric Surgery, University of Health Sciences, Ümraniye Training and Research Hospital, İstanbul-Türkiye
| | - Fatma Tuğba Güvenç
- Department of Pediatric Surgery, University of Health Sciences, Ümraniye Training and Research Hospital, İstanbul-Türkiye
| | - Mehmet Arpacık
- Department of Pediatric Surgery, University of Health Sciences, Ümraniye Training and Research Hospital, İstanbul-Türkiye
| | - Zekeriya İlce
- Department of Pediatric Surgery, University of Health Sciences, Ümraniye Training and Research Hospital, İstanbul-Türkiye
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5
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Taylor K, Rivere E, Jagneaux T, LeBoeuf G, Estela K, Pierce C, O’Neal C. Clinical characteristics and outcomes of SARS-Cov-2 B.1.1.529 infections in hospitalized patients and multi-surge comparison in Louisiana. PLoS One 2022; 17:e0268853. [PMID: 36269696 PMCID: PMC9586372 DOI: 10.1371/journal.pone.0268853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Accepted: 10/08/2022] [Indexed: 11/07/2022] Open
Abstract
Background Peer reviewed data describing SARS-CoV-2 Omicron variant symptoms and clinical outcomes as compared to prior surges in the United States is thus far limited. We sought to determine disease severity, presenting features, and epidemiologic factors of the SARS-CoV-2 Omicron variant compared to prior surges. Methods Retrospective cohort analysis was performed on patients admitted during five surges in Louisiana between March 2020 and January 2022. Patient data was pulled from the medical record and a subset of patients during Surge 5 were manually abstracted. Patients who were admitted to one of six Louisiana hospitals with a positive SARS-CoV-2 test during the 5 defined surge periods were included. Surges were compared using chi-squared tests and one way ANOVA for age, sex, vaccination status, length of stay, ICU status, ventilation requirement, and disposition at discharge. The records of patients admitted during the omicron surge were analyzed for presenting symptoms and incidental SARS-CoV-2 diagnosis. Results With each subsequent surge, a smaller proportion of patients presenting to the emergency department were admitted. Patients admitted during surge 5 had shorter lengths of stay and fewer comorbidities than prior surges. Fewer patients in surge 5 presented with a respiratory condition and fewer required ICU admission. In surges 4 and 5, fewer vaccinated patients were admitted compared to their unvaccinated counterparts. Overall mortality was lower in surge 5 (9%) than in surge 4 (15%) p < .0005. Of the SARS-Cov-2 admissions in surge 5, 22.3% were felt to be incidental diagnoses. Conclusions As the COVID-19 pandemic progressed, a younger and less vaccinated population was associated with higher risk for severe disease, fewer patients required ICU admission and overall mortality decreased. Vaccinations seemed to be protective for overall risk of hospitalization but once admitted did not seem to confer additional protection against severe illness during the omicron surge. Age also contributed to patient outcomes.
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Affiliation(s)
- Katie Taylor
- Franciscan Missionaries of Our Lady Health System, Baton Rouge, LA, United States of America
- Louisiana State University Health Sciences Center, Baton Rouge, LA, United States of America
| | - Evan Rivere
- Franciscan Missionaries of Our Lady Health System, Baton Rouge, LA, United States of America
- Louisiana State University Health Sciences Center, Baton Rouge, LA, United States of America
- * E-mail:
| | - Tonya Jagneaux
- Franciscan Missionaries of Our Lady Health System, Baton Rouge, LA, United States of America
- Louisiana State University Health Sciences Center, Baton Rouge, LA, United States of America
| | - Gabrielle LeBoeuf
- Franciscan Missionaries of Our Lady Health System, Baton Rouge, LA, United States of America
| | - Karen Estela
- Franciscan Missionaries of Our Lady Health System, Baton Rouge, LA, United States of America
| | - Christi Pierce
- Franciscan Missionaries of Our Lady Health System, Baton Rouge, LA, United States of America
| | - Catherine O’Neal
- Franciscan Missionaries of Our Lady Health System, Baton Rouge, LA, United States of America
- Louisiana State University Health Sciences Center, Baton Rouge, LA, United States of America
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6
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Vansevičienė I, Krunkaitytė U, Dekerytė I, Beržanskis M, Lukošiūtė-Urbonienė A, Malcius D, Barauskas V. Does Multisystem Inflammatory Syndrome Only Mimic Acute Appendicitis in Children or Can It Coexist: When Should We Suspect MIS-C? Medicina (Kaunas) 2022; 58. [PMID: 36013568 DOI: 10.3390/medicina58081101] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Revised: 08/05/2022] [Accepted: 08/12/2022] [Indexed: 11/17/2022]
Abstract
Background and Objectives: Acute abdominal pain in children has been noticed to be a primary reason to seek medical attention in multisystem inflammatory disorder (MIS-C), which can prevail separately or together with acute appendicitis. Our aim was to distinguish regular appendicitis cases from MIS-C and to suggest the best clinical and laboratory criteria for it. Materials and methods: Cases of patients, admitted to the Pediatric Surgery Department over a six-month period in 2021, were retrospectively analyzed. Confirmed MIS-C or acute appendicitis cases were selected. MIS-C cases were either separate/with no found inflammation in the appendix or together with acute appendicitis. Acute appendicitis cases were either regular cases or with a positive COVID-19 test. Four groups were formed and compared: A-acute appendicitis, B-MIS-C with acute appendicitis, C-MIS-C only and D-acute appendicitis with COVID-19. Results: A total of 76 cases were overall analyzed: A-36, B-6, C-29 and D-5. The most significant differences were found in duration of disease A—1.4 days, B—4.5 days, C—4 days, D—4 days (p < 0.0001), C reactive protein (CRP) values A-19.3 mg/L B-112.5 m/L, C-143.8 mg/L and D-141 mg/L (p < 0.0001), presence of febrile fever A-13.9%, B-66.7%, C-96.6% and D-40% (p < 0.0001) and other system involvement: A 0%, B 100%, C 100% and D 20%. A combination of these factors was entered into a ROC curve and was found to have a possibility to predict MIS-C in our analyzed cases (with or without acute appendicitis) with an AUC = 0.983, p < 0.0001, sensitivity of 94.3% and specificity of 92.7% when at least three criteria were met. Conclusions: MIS-C could be suspected even when clinical data and performed tests suggest acute appendicitis especially when at least three out of four signs are present: CRP > 55.8 mg, symptoms last 3 days or longer, febrile fever is present, and any kind of other system involvement is noticed, especially with a known prior recent COVID-19 contact, infection or a positive COVID-19 antibody IgG test.
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7
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Jiang Y, Mehl SC, Hawes EE, Lino AS, Rialon KL, Murray KO, Ronca SE. SARS-CoV-2 Infection Is Not Associated With Pediatric Appendicitis. Pediatr Infect Dis J 2022; 41:e321-e323. [PMID: 35622441 PMCID: PMC9281423 DOI: 10.1097/inf.0000000000003575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/15/2022] [Indexed: 11/26/2022]
Abstract
Although case reports have suggested an association between severe acute respiratory distress syndrome coronavirus 2 and appendicitis, we found that the overall incidence of appendicitis was stable throughout the pandemic at our tertiary pediatric hospital. Furthermore, we did not find evidence of CoV2 infection in 9 appendicitis tissues. Therefore, we conclude that severe acute respiratory distress syndrome coronavirus 2 infection of the appendix is not a common etiologic cause of pediatric appendicitis.
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Affiliation(s)
- Yike Jiang
- From the Department of Pediatrics, Texas Children’s Hospital and Baylor College of Medicine, Houston, Texas
| | - Steven C. Mehl
- Department of Surgery, Texas Children’s Hospital and Baylor College of Medicine, Houston, Texas
| | - Ella E. Hawes
- From the Department of Pediatrics, Texas Children’s Hospital and Baylor College of Medicine, Houston, Texas
| | - Allison S. Lino
- From the Department of Pediatrics, Texas Children’s Hospital and Baylor College of Medicine, Houston, Texas
| | - Kristy L. Rialon
- Department of Surgery, Texas Children’s Hospital and Baylor College of Medicine, Houston, Texas
| | - Kristy O. Murray
- From the Department of Pediatrics, Texas Children’s Hospital and Baylor College of Medicine, Houston, Texas
- Department of Microbiology and Immunology, Baylor College of Medicine, Houston, Texas
- William T. Shearer Center for Human Immunobiology, Department of Pediatrics, Texas Children’s Hospital, Houston, Texas
| | - Shannon E. Ronca
- From the Department of Pediatrics, Texas Children’s Hospital and Baylor College of Medicine, Houston, Texas
- Department of Microbiology and Immunology, Baylor College of Medicine, Houston, Texas
- William T. Shearer Center for Human Immunobiology, Department of Pediatrics, Texas Children’s Hospital, Houston, Texas
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8
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Sundland R, Essig R, Bachier-Rodriguez M. Lessons Learned from the Surgical Management of Childhood Cancers During the COVID-19 Pandemic. Pediatr Ann 2022; 51:e270-e276. [PMID: 35858216 DOI: 10.3928/19382359-20220504-06] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Globally, there have been more than 285 million confirmed cases of coronavirus disease 2019 (COVID-19), with nearly 5.5 million deaths. Centers for Disease Control and Prevention data report that in the United States alone, there have been more than 59 million cases of COVID-19 with more than 800,000 lives lost as of January 2022. Similar to other health care specialties, pediatric surgery departments have modified their treatment approach to delivering timely care while respecting resource allocation during the pandemic. In this review, we focus on the surgical management of pediatric patients, with specific attention to childhood cancer. The primary subject of this review is the development of triaging methods for patients with childhood cancer for surgical procedures and precautionary measures for operating on patients with COVID-19. [Pediatr Ann. 2022;51():e270-e276.].
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Abstract
Coronavirus disease 2019 (COVID-19) is an ongoing pandemic caused by the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) virus. More than 5 million children have been infected in the United States. Risk factors for more severe disease progression include obesity, pulmonary disease, gastrointestinal disorders, and neurologic comorbidities. Children with COVID-19 are admitted to the pediatric intensive care unit because of severe acute COVID-19 illness or COVID-19-associated multisystem inflammatory syndrome in children. The delta surge of 2021 was responsible for an increased disease burden in children and points to the key role of vaccinating children against this sometimes-deadly disease.
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Affiliation(s)
- Meena Kalyanaraman
- Pediatric Critical Care Medicine, Children's Hospital of New Jersey at Newark Beth Israel Medical Center, C-5, 201 Lyons Avenue, Newark, NJ 07112, USA.
| | - Michael R. Anderson
- Children’s National Hospital, George Washington University School of Medicine and Health Sciences
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10
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Koloamatangi M, Le-Madison A, Parsh B. COVID-19 and appendicitis in children. Nursing 2022; 52:11. [PMID: 35609067 DOI: 10.1097/01.nurse.0000829880.68035.16] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Mary Koloamatangi
- Mary Koloamatangi is a BSN student at the California State University of Sacramento (CSUS) School of Nursing. Asia Le-Madison is an RN in the Neonatal Intensive Care Unit at UC Davis Medical Center in Sacramento, CA. Bridget Parsh is a professor at CSUS and a member of the Nursing2022 editorial board
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11
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Azılı MN, Güney D, Oztorun CI, Ertürk A, Erten EE, Demir S, Ertoy A, Emeksiz S, Parlakay AO, Celikel BA, Senel E. Determination of Factors to Distinguish MIS-C from Acute Appendicitis in Children with Acute Abdominal Pain. Eur J Pediatr Surg 2022; 32:240-250. [PMID: 34298578 DOI: 10.1055/s-0041-1732320] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
INTRODUCTION The aim of this study was to make the differential diagnosis between acute appendicitis and multisystem inflammatory syndrome in children (MIS-C) for patients presenting with the complaint of acute abdominal pain (AAP) and to identify the determining factors for the diagnosis of MIS-C. MATERIALS AND METHODS Eighty-one children presenting with AAP/suspected AAP were evaluated. Of these, 24 (29.6%) were included in the MIS-C group (MIS-C/g) and 57 were included in the suspected appendicitis group (S-A/g), which consisted of two subgroups: appendicitis group (A/g) and control observation group (CO/g). RESULTS Comparing MIS-C/g, A/g, and CO/g, duration of abdominal pain (2.4, 1.5, 1.8 days), high-grade fever (38.8, 36.7, 37°C), severe vomiting, and severe diarrhea were higher in MIS-C/g. Lymphocytes count (LC) was lower, while values of C-reactive protein (CRP), ferritin, and coagulopathy were higher in MIS-C/g (p < 0.05). The optimal cutoffs for the duration of abdominal pain was 2.5 days; the duration of fever, 1.5 days; peak value of fever, 39°C; neutrophil count, 13,225 × 1,000 cell/µMoL; LC, 600 × 1,000 cell/µMoL; ferritin, 233 µg/L; and D-dimer, 16.4 mg/L (p < 0.05). The optimal cutoff for CRP was 130 mg/L (sensitivity 88.9, specificity 100%, positive predictive value 100%, NPV, negative predictive value 92.5%, p < 0.001). All patients in MIS-C/g tested positive by serology by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). CONCLUSION The duration of abdominal pain, presence of high-grade and prolonged fever, and evaluation of hemogram in terms of high neutrophil count and low LC exhibit high sensitivity and negative predictive value for MIS-C presenting with AAP. In case of doubt, inflammatory markers such as CRP, ferritin, D-dimer, and serology for SARS-CoV-2 should be studied to confirm the diagnosis.
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Affiliation(s)
- Müjdem Nur Azılı
- Department of Pediatric Surgery, Ankara City Children's Hospital, Ankara Yildirim Beyazit University, Ankara, Turkey.,Department of Pediatric Surgery, Ankara City Hospital, Cankaya, Ankara, Turkey
| | - Doğuş Güney
- Department of Pediatric Surgery, Ankara City Children's Hospital, Ankara Yildirim Beyazit University, Ankara, Turkey.,Department of Pediatric Surgery, Ankara City Hospital, Cankaya, Ankara, Turkey
| | - Can Ihsan Oztorun
- Department of Pediatric Surgery, Ankara City Children's Hospital, Ankara Yildirim Beyazit University, Ankara, Turkey.,Department of Pediatric Surgery, Ankara City Hospital, Cankaya, Ankara, Turkey
| | - Ahmet Ertürk
- Department of Pediatric Surgery, Ankara City Hospital, Cankaya, Ankara, Turkey
| | - Elif Emel Erten
- Department of Pediatric Surgery, Ankara City Hospital, Cankaya, Ankara, Turkey
| | - Sabri Demir
- Department of Pediatric Surgery, Ankara City Hospital, Cankaya, Ankara, Turkey
| | - Ayşe Ertoy
- Department of Pediatric Surgery, Ankara City Hospital, Cankaya, Ankara, Turkey
| | - Serhat Emeksiz
- Department of Pediatric Intensive Care, Ankara Yildirim Beyazit University, Ankara, Turkey.,Department of Pediatric Intensive Care, Ankara City Hospital, Cankaya, Ankara, Turkey
| | - Aslınur Ozkaya Parlakay
- Department of Pediatric Infection, Ankara Yildirim Beyazit University, Ankara, Turkey.,Department of Pediatric Infection, Ankara City Hospital, Cankaya, Ankara, Turkey
| | - Banu Acar Celikel
- Department of Pediatric Rheumatology, Ankara City Hospital, Cankaya, Ankara, Turkey
| | - Emrah Senel
- Department of Pediatric Surgery, Ankara City Children's Hospital, Ankara Yildirim Beyazit University, Ankara, Turkey.,Department of Pediatric Surgery, Ankara City Hospital, Cankaya, Ankara, Turkey
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12
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Boybeyi-Turer O, Ozsurekci Y, Gurlevik SL, Oygar PD, Soyer T, Tanyel FC. Management of acute abdomen during the active disease course of COVID-19 and multisystem inflammatory syndrome in children. Surg Today 2022; 52:1313-1319. [PMID: 35513506 PMCID: PMC9070979 DOI: 10.1007/s00595-022-02512-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Accepted: 12/09/2021] [Indexed: 11/28/2022]
Abstract
Purpose To evaluate the management of children with severe gastrointestinal symptoms during the disease course of COVID-19 and multisystem inflammatory syndrome (MIS-C). Methods After ethical approval, we reviewed the medical records, retrospectively, of children with COVID-19 or MIS-C requiring surgical consultation for severe gastrointestinal symptoms. Results The subjects comprised 15 children, 13 with MIS-C and 2 with COVID-19. Twelve children (80%) had been in known close contact with a person with SARS-CoV-19 and 13 were positive for Anti-SARS-CoV-2 IgG. All the children had experienced fever for at least 1 day and had signs of involvement of two or more systems. Three patients required surgical intervention: one underwent surgical exploration with a presumptive diagnosis of acute appendicitis in the referring center and was transported to our center following clinical deterioration, where a diagnosis of MIS-C was confirmed; and the remaining two developed appendicitis during hospitalization for COVID-19. All three patients had a longer duration of abdominal pain, a higher number of lymphocytes, and a lower level of inflammatory markers than the non-surgically managed patients. None of the patients presenting with MIS-C underwent surgical exploration. Conclusion Gastrointestinal involvement may mimic acute abdomen in children with COVID-19. Thus, children presenting with acute abdomen in the pandemic era require careful evaluation and prompt diagnosis to avoid unnecessary surgical intervention.
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Affiliation(s)
- Ozlem Boybeyi-Turer
- Faculty of Medicine, Department of Pediatric Surgery, Hacettepe University, Ankara, Turkey.
| | - Yasemin Ozsurekci
- Faculty of Medicine, Department of Pediatric Infectious Diseases, Hacettepe University, Ankara, Turkey
| | - Sibel Lacinel Gurlevik
- Faculty of Medicine, Department of Pediatric Infectious Diseases, Hacettepe University, Ankara, Turkey
| | - Pembe Derin Oygar
- Faculty of Medicine, Department of Pediatric Infectious Diseases, Hacettepe University, Ankara, Turkey
| | - Tutku Soyer
- Faculty of Medicine, Department of Pediatric Surgery, Hacettepe University, Ankara, Turkey
| | - Feridun Cahit Tanyel
- Faculty of Medicine, Department of Pediatric Surgery, Hacettepe University, Ankara, Turkey
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13
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Abstract
PURPOSE OF THE REVIEW The pandemic of coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has emerged and caused a massive global health crisis. The aim of this review is first, to provide the latest evidence on what is known about the pathophysiology and the transmission of SARS-CoV-2 and then to focus on the manifestations of the gastrointestinal (GI) tract in children with COVID-19. Lastly, we summarise the impact of COVID-19 on patients with preexisting GI diseases. RECENT FINDINGS Even though the virus is mostly transmitted from human to human via respiratory droplets, ACE2 is known to be expressed throughout the GI tract, and SARS-CoV-2 ribonucleic acid has been isolated from patients' stools. GI symptoms including abdominal pain, diarrhoea and vomiting are frequently reported in paediatric patients. Interestingly, a small number of patients seem to exhibit solely GI symptoms. In addition, a multisystem inflammatory syndrome in children (MIS-C) related to SARS-COV-2 described in children, has a high rate of GI involvement. Several etiopathogenetic mechanisms have been postulated to explain the GI involvement of COVID-19. SUMMARY Clinicians should not underestimate or disregard these early or mild GI symptoms, because the patients may be infected and transmit the virus, or develop a more severe condition such as MIS-C.
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Affiliation(s)
- Naire Sansotta
- Paediatric Hepatology Gastroenterology and Transplantation, Papa Giovanni XXIII Hospital, Bergamo, Italy
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14
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Nurnaningsih, Danudibroto GI, Rusmawatiningtyas D, Kumara IF, Makrufardi F, Widowati T. Acute appendicitis in pediatric patients with Coronavirus Disease 2019 (COVID-19): A case series from a developing country's tertiary hospital. Ann Med Surg (Lond) 2022;:103315. [PMID: 35096389 DOI: 10.1016/j.amsu.2022.103315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 01/18/2022] [Accepted: 01/23/2022] [Indexed: 11/29/2022] Open
Abstract
Introduction and importance: A common gastrointestinal presentation of both COVID-19 and multisystem inflammatory syndrome in children (MIS-C) is acute abdominal pain, which sometimes mimics appendicitis. Literature describing children with COVID-19 infection and concurrent acute appendicitis is growing, and understanding these patients’ clinical picture is necessary for their proper treatment. Case presentation We present a case series of six healthy children before they developed classic symptoms of appendicitis. At the same time, they were also found to have confirmed COVID-19. All patients had fever and right lower abdominal pain. Four of six children having Alvarado score above seven had surgical treatment, while the others only received systemic antibiotic and antiviral medication. Surgical results of two patients revealed perforated appendicitis. No mortality occurred among them. Clinical discussion There is increasing recognition of gastrointestinal involvement in patients with COVID-19 and MIS-C. There are several postulates to explain appendicitis in COVID-19. First, inflammatory response is exaggerated in SARS-CoV-2 infected patients. Second, obstruction of the appendiceal lumen is caused by mesenteric adenopathy, which in turn, is caused by COVID-19 infection, not fecalith. Third, hyperinflammatory response in MIS-C triggers inflammation in appendix. Conclusion Clinicians must recognize that abdominal pain with fever could be the presenting symptoms of COVID-19 with MIS-C. MIS-C, which has severe presentations with gastrointestinal manifestations and high mortality rate, should be considered as a differential diagnosis for a patient with appendicitis-like symptoms and a positive SARS-CoV-2 infection. Inflammatory response is exaggerated in SARS-CoV-2 infected patients. Obstruction of the appendiceal lumen is caused by mesenteric adenopathy. Hyperinflammatory response in MIS-C triggers inflammation in appendix.
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15
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Vaos G, Zavras N. Severe acute respiratory syndrome coronavirus 2 pandemic related morbidity and mortality in patients with pediatric surgical diseases: A concerning challenge. World J Methodol 2022; 12:20-31. [PMID: 35117979 PMCID: PMC8790310 DOI: 10.5662/wjm.v12.i1.20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 07/01/2021] [Accepted: 11/15/2021] [Indexed: 02/06/2023] Open
Abstract
The global spread of the novel severe acute respiratory syndrome coronavirus 2 has had serious consequences in terms of patient morbidity and mortality and overburdened health care systems as well as the socioeconomic implications. In the absence of effective therapies and vaccinations during the viral outbreak, the major and most concise means to control viral spread is spread prevention. Although information concerning the impact of severe acute respiratory syndrome coronavirus 2 on pediatric surgical patients has greatly expanded, relevant comprehensive studies are scarce. However, pandemic related morbidity has increased, while under normal circumstances mortality could have been minimized.
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Affiliation(s)
- George Vaos
- Department of Paediatric Surgery, “ATTIKON” University General Hospital, National and Kapodistrian University of Athens, School of Medicine, Athens 12462, Greece
| | - Nikolaos Zavras
- Department of Paediatric Surgery, “ATTIKON” University General Hospital, National and Kapodistrian University of Athens, School of Medicine, Athens 12462, Greece
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16
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Fabi M, Vasuri F, Guida F, Rocca A, Lima M, D'Errico A, Lanari M. Case report: Histological findings of peri-appendicitis in three children with SARS-CoV-2 - related multisystem inflammatory syndrome: A mark for systemic inflammation? Front Pediatr 2022; 10:975940. [PMID: 36467465 PMCID: PMC9714539 DOI: 10.3389/fped.2022.975940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Accepted: 10/19/2022] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Multisystem inflammatory syndrome in children (MIS-C) is a rare but serious condition that can potentially develop after SARS-CoV-2 infection in children. Gastrointestinal manifestation in MIS-C can mimic acute abdomen, potentially leading to unnecessary surgical treatment. Immune-mediated mechanisms seem to be a determining factor in its pathogenesis, and histological studies can help to shed light on this aspect. We describe three cases of children diagnosed with MIS-C that underwent appendectomy. METHODS We retrospectively collected the clinical features and histological findings of three previously healthy children who underwent appendectomy for clinical suspicion of acute appendicitis but were later diagnosed with MIS-C. FINDINGS The three children presented with prominent abdominal manifestations and fever leading to the suspicion of acute abdomen. Histological findings showed transmural and perivascular inflammation. Notably, CD68+ macrophages were predominant in the child with milder abdominal symptoms without cardiac injury, while CD3+ lymphocytes in the patient presented with more severe abdominal pain and cardiovascular involvement at admission. INTERPRETATION Gastrointestinal symptoms of children with MIS-C improve after proper immunomodulatory therapy, conversely showing inadequate response to surgical appendectomy. Histological findings revealed different inflammatory cell infiltration that primarily involved perivisceral fat and vessels, and subsequently mucosal tissue, in contrast to other forms of acute appendicitis. Our findings suggest that this kind of peri-appendicitis in MIS-C could represent a focal sign of systemic inflammation, with different histological patterns compared to other forms of acute appendicitis.
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Affiliation(s)
- Marianna Fabi
- Division of Pediatric Emergency, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Francesco Vasuri
- Pathology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Fiorentina Guida
- Speciality School of Pediatrics, Sant'Orsola-Malpighi Hospital, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Alessandro Rocca
- Division of Pediatric Emergency, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Mario Lima
- Division of Pediatric Surgery Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Antonietta D'Errico
- Pathology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Marcello Lanari
- Division of Pediatric Emergency, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
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17
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Salman R, Sher AC, Guillerman RP, Seghers VJ, Rodriguez JR, Sangi-Haghpeykar H, Annapragada AV, Sammer MBK. Acute appendicitis and SARS-CoV-2 in children: imaging findings at a tertiary children's hospital during the COVID-19 pandemic. Pediatr Radiol 2022; 52:460-7. [PMID: 34741178 DOI: 10.1007/s00247-021-05219-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 09/09/2021] [Accepted: 10/05/2021] [Indexed: 10/26/2022]
Abstract
BACKGROUND Evidence suggests severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection may be associated with appendicitis or clinical symptoms that mimic appendicitis, but it is not clear if the findings or utility of imaging in pediatric patients with suspected appendicitis have changed since the onset of the coronavirus disease 2019 (COVID-19) pandemic. OBJECTIVE To evaluate for potential differences in SARS-CoV-2 positive and SARS-CoV-2 negative pediatric patients imaged for suspected appendicitis to determine the reliability of the existing medical imaging approach for appendicitis in a population that contains both SARS-CoV-2 positive and SARS-CoV-2 negative pediatric patients. MATERIALS AND METHODS Patients imaged for suspected appendicitis Apr. 1, 2020, to Dec. 31, 2020, were identified via an electronic medical records search. Differences in ultrasound (US) diagnostic performance, use of computed tomography (CT) following US, rates of appendicitis, imaging findings of appendicitis and perforation were compared between SARS-CoV-2 positive and SARS-CoV-2 negative tested patients, using pathology and surgery as reference standards for appendicitis and perforation, respectively. Fisher exact test and Student's t-test were used for statistical analysis. RESULTS One thousand, six hundred and ninety-three patients < 18 years old met inclusion criteria, with 46% (772/1,693) female, 11 imaged with only CT and 1,682 with US. Comparing SARS-CoV-2 positive and SARS-CoV-2 negative patients, no statistically significant differences in sensitivity or specificity of US (P = 1 and P = 1, respectively), or in the US (P-values ranging from 0.1 to 1.0) or CT imaging findings (P-values ranging from 0.2 to 1.0) in appendicitis were found. Perforation rates were similar between SARS-CoV-2 positive (20/57, 35.1% perforated) and SARS-CoV-2 negative (359/785, 45.7% perforated) patients with appendicitis (P = 0.13). Use of CT following first-line US was similar, with 7/125 (5.6%) of SARS-CoV-2 positive imaged with CT after US and 127/1,557 (8.2%) of SARS-CoV-2 negative imaged with CT after US (P = 0.39). CONCLUSION In pediatric patients with suspected appendicitis, no significant difference was found in the diagnostic performance of US, CT usage or perforation rates between SARS-CoV-2 positive and SARS-CoV-2 negative patients.
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18
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Engelis A, Smane L, Pavare J, Zviedre A, Zurmutai T, Berezovska MM, Bormotovs J, Kakar M, Saxena AK, Petersons A. Case Series of Variable Acute Appendicitis in Children with SARS-CoV-2 Infection. Children 2021; 8:1207. [PMID: 34943404 PMCID: PMC8699863 DOI: 10.3390/children8121207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Revised: 12/09/2021] [Accepted: 12/18/2021] [Indexed: 11/17/2022]
Abstract
This case series study consists of six children, aged 5–16 years, admitted to a centralized tertiary paediatric hospital serving a population of 1.9 million with acute appendicitis in the setting of SARS-CoV-2 infection. From the beginning of the pandemic in March 2020 until August 2021, 121 COVID-19-positive children were admitted to the hospital. A total of 49 (40.5%) of these patients presented with gastrointestinal symptoms, of which six were diagnosed with acute appendicitis. Five underwent an appendectomy, while one was treated conservatively. To date, it has been reported that appendicitis may have a plausible association with SARS-CoV-2 infection in children. With COVID-19 cases rising, every medical specialist, including all paediatric surgeons, must be ready to treat common acute diseases with SARS-CoV-2 infection as a comorbidity. Providers should consider testing for this infection in paediatric patients with severe gastrointestinal symptoms. Non-surgical treatment of acute appendicitis in children may gain new importance during and after the COVID-19 pandemic. Further studies are needed to prove the link of causality between COVID-19 and acute appendicitis in children.
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19
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Abstract
Acute appendicitis is a rare complication of Kawasaki disease in the setting of the absence of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). We experienced a rare case of acute appendicitis associated with Kawasaki disease. The patient is a six-year-old male who was brought to the emergency department by his mother with a pruritic rash, nausea, vomiting, and abdominal pain. Given fever, tenderness in the right lower quadrant on physical examination, leukocytosis with bandemia, and a non-compressible and dilated appendix on ultrasound, he was diagnosed with acute appendicitis and was treated with a laparoscopic appendectomy. He developed persistent fevers after surgery with new lip swelling, mucositis, and bilateral conjunctival injection. Kawasaki disease was suspected and intravenous gammaglobulin and aspirin were administrated. He made a full recovery. This case suggests that careful examination is needed for accurate diagnosis, especially in patients with postoperative persistent fever without signs of intra-abdominal complications. We performed a PubMed literature search and reviewed eight cases of appendicitis associated with Kawasaki disease. Of note, this case was seen in 2018 before the SARS-CoV-2 pandemic and the description of multisystem inflammatory syndrome in children (MIS-C).
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Affiliation(s)
- Kaku Kuroda
- Family Medicine, State University of New York (SUNY) Upstate Medical University, Syracuse, USA.,Pediatrics, United States Naval Hospital Okinawa, Ginowan, JPN
| | - Morgan Stottlemyre
- Pediatrics, Washington University School of Medicine, St. Louis, USA.,Pediatrics, United States Naval Hospital Okinawa, Ginowan, JPN
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20
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Teng TZJ, Thong XR, Lau KY, Balasubramaniam S, Shelat VG. Acute appendicitis–advances and controversies. World J Gastrointest Surg 2021; 13:1293-1314. [PMID: 34950421 PMCID: PMC8649565 DOI: 10.4240/wjgs.v13.i11.1293] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 06/24/2021] [Accepted: 09/29/2021] [Indexed: 02/06/2023] Open
Abstract
Being one of the most common causes of the acute abdomen, acute appendicitis (AA) forms the bread and butter of any general surgeon’s practice. With the recent advancements in AA’s management, much controversy in diagnostic algorithms, possible differential diagnoses, and weighing the management options has been generated, with no absolute consensus in the literature. Since Alvarado described his eponymous clinical scoring system in 1986 to stratify AA risk, there has been a burgeoning of additional scores for guiding downstream management and mortality assessment. Furthermore, advancing literature on the role of antibiotics, variations in appendicectomy, and its adjuncts have expanded the surgeon’s repertoire of management options. Owing to the varied presentation, diagnostic tools, and management of AA have also been proposed in special groups such as pregnant patients, the elderly, and the immunocompromised. This article seeks to raise the critical debates about what is currently known about the above aspects of AA and explore the latest controversies in the field. Considering the ever-evolving coronavirus disease 2019 situation worldwide, we also discuss the pandemic’s repercussions on patients and how surgeons’ practices have evolved in the context of AA.
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Affiliation(s)
- Thomas Zheng Jie Teng
- Department of General Surgery, Tan Tock Seng Hospital, Singapore 308433, Singapore
- Department of Undergraduate Medicine, Lee Kong Chian School of Medicine, Singapore 308232, Singapore
| | - Xuan Rong Thong
- Department of General Surgery, Tan Tock Seng Hospital, Singapore 308433, Singapore
- Department of Undergraduate Medicine, Lee Kong Chian School of Medicine, Singapore 308232, Singapore
| | - Kai Yuan Lau
- Department of General Surgery, Tan Tock Seng Hospital, Singapore 308433, Singapore
- Department of Undergraduate Medicine, Lee Kong Chian School of Medicine, Singapore 308232, Singapore
| | | | - Vishal G Shelat
- Department of General Surgery, Tan Tock Seng Hospital, Singapore 308433, Singapore
- Department of Undergraduate Medicine, Lee Kong Chian School of Medicine, Singapore 308232, Singapore
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21
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Yock-Corrales A, Lenzi J, Ulloa-Gutiérrez R, Gómez-Vargas J, Antúnez-Montes OY, Rios Aida JA, del Aguila O, Arteaga-Menchaca E, Campos F, Uribe F, Díaz RH, Buitrago AP, Londoño LMB, Kozicki V, Brizuela M, Buonsenso D. Acute Abdomen and Appendicitis in 1010 Pediatric Patients With COVID-19 or MIS-C: A Multinational Experience from Latin America. Pediatr Infect Dis J 2021; 40:e364-e369. [PMID: 34260501 PMCID: PMC8443421 DOI: 10.1097/inf.0000000000003240] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/20/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND To date, there are only sporadic reports of acute abdomen and appendicitis in children with coronavirus disease 2019 (COVID-19) and multisystem inflammatory syndrome in children (MIS-C). METHODS Children 17 years of age or younger assessed in 5 Latin American countries with a diagnosis of microbiologically confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and children fulfilling MIS-C definition were included. For children with acute abdomen, we investigate main radiologic patterns, surgical treatment and intraoperative findings, outcomes. FINDINGS One-thousand ten children were enrolled. Forty-two children (4.2%) had a clinical diagnosis of acute abdomen. Four (9.5%) were diagnosed with MIS-C and did not undergo surgery. The remaining 38 children (3.8%) underwent abdominal surgery due to suspected appendicitis, 34 of them (89.7%) had an intraoperative diagnosis of acute appendicitis (AA), while 4 of them had nonsurgical findings. Eight children died (0.8%), none of them being diagnosed with appendicitis. Children with AA were significantly older than those without (P < 0.0001). Children with complicated appendicitis had more frequently fever (85.7% vs. 60%), intestinal distension on the abdominal radiograph (7.1% vs. none), leukocytosis (85.7% vs. 40%) and high levels of C-reactive protein (35.7% vs. 5%), although differences were not statistically significant. CONCLUSIONS Our study showed that children may present with acute abdomen during COVID-19 or MIS-C, which is not always associated with intraoperative findings of appendicitis, particularly in case of MIS-C. Further studies are needed to better characterize children with acute abdomen during COVID-19 or MIS-C, to avoid delay in diagnosis of surgical conditions and at the same time, minimize unnecessary surgical approaches.
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Affiliation(s)
- Adriana Yock-Corrales
- From the Pediatric Emergency Department, Hospital Nacional de Niños “Dr. Carlos Sáenz Herrera”, CCSS, San José, Costa Rica
| | - Jacopo Lenzi
- Department of Biomedical and Neuromotor Sciences, Alma Mater Studiorum – University of Bologna, Bologna, Italy
| | - Rolando Ulloa-Gutiérrez
- Infectious Disease Department, Hospital Nacional de Niños “Dr. Carlos Sáenz Herrera”, CCSS, San José, Costa Rica
| | - Jessica Gómez-Vargas
- From the Pediatric Emergency Department, Hospital Nacional de Niños “Dr. Carlos Sáenz Herrera”, CCSS, San José, Costa Rica
| | - Omar Yassef Antúnez-Montes
- Departamento de Docencia e Investigación, Instituto Latinoamericano de Ecografía en Medicina (ILEM), Ciudad de Mexico, Mexico
| | | | - Olguita del Aguila
- Department of Pediatrics, Unidad de Infectología Pediátrica del Hospital Nacional Edgardo Rebagliati Martins-Lima-Perú
| | | | - Francisco Campos
- Department of Pediatrics, Hospital Madre Niño San Bartolome, Lima, Peru
| | - Fadia Uribe
- Department of Pediatrics, Hospital Madre Niño San Bartolome, Lima, Peru
| | | | - Andrea Parra Buitrago
- Department of Pediatrics, Hospital Pablo Tobon Uribe Medellin, Colombia
- Department of Pediatrics, Fundacion Neumologica Colombiana, Bogotà, Colombia
| | | | - Verónica Kozicki
- Pediatric Infectious Disease, Hospital isidoro Iriarte, Quilmes, Buenos Aires, Argentina
| | - Martin Brizuela
- Pediatric Infectious Disease, Hospital isidoro Iriarte, Quilmes, Buenos Aires, Argentina
| | - Danilo Buonsenso
- Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario A. Gemelli, Rome, Italy
- Dipartimento di Scienze Biotecnologiche di Base, Cliniche Intensivologiche e Perioperatorie, Università Cattolica del Sacro Cuore, Rome, Italy
- Department of Pediatrics, Global Health Research Institute, Istituto di Igiene, Università Cattolica del Sacro Cuore, Roma, Italia
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22
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Nurullayev E, Gördü B, Özsürekçi Y, Haliloglu M, Soyer T. Acute appendicitis during the clinical course of COVID-19 in a 13-year-old boy: Complication or coincidental? Surg Pract 2021; 25:232-234. [PMID: 34899958 PMCID: PMC8652558 DOI: 10.1111/1744-1633.12526] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Gastrointestinal symptoms appear to be one of the most common presentations of SARS‐CoV‐2 infection, later named COVID‐19. The symptoms such as nausea, emesis, abdominal pain, and diarrhoea may be recognised as either a finding of COVID‐19 or prominent presentation of multi‐inflammatory syndrome in children (MIS‐C). COVID‐19 may present with acute appendicitis and/or may mimic its clinical findings. Although, coexistence of acute appendicitis and COVID‐19 has been well documented, it is not clear whether appendicitis is a complication of COVID‐19 or coincidence in children. A 13‐year‐old boy who developed acute appendicitis during the clinical course of COVID‐19 is presented to discuss the possibility of causal relationship between appendicitis and COVID‐19 in children.
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Affiliation(s)
- Elnur Nurullayev
- Faculty of Medicine, Departments of Paediatric Surgery Hacettepe University Ankara Turkey
| | - Bilge Gördü
- Faculty of Medicine, Departments of Paediatric Surgery Hacettepe University Ankara Turkey
| | - Yasemin Özsürekçi
- Departments of Paediatric Infectious Disease Hacettepe University Ankara Turkey
| | - Mithat Haliloglu
- Departments of Paediatric Radiology Hacettepe University Ankara Turkey
| | - Tutku Soyer
- Faculty of Medicine, Departments of Paediatric Surgery Hacettepe University Ankara Turkey
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23
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Ardila Gómez IJ, López PP, Duque DC, García DMS, Romero AF, Vega MRV, Ramos Castañeda JA. Abdominal manifestation of multisystemic inflammatory syndrome in children. J Pediatr Surg Case Rep 2021; 74:102042. [PMID: 34545321 PMCID: PMC8444470 DOI: 10.1016/j.epsc.2021.102042] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Revised: 09/14/2021] [Accepted: 09/15/2021] [Indexed: 12/29/2022] Open
Abstract
Summary Multisystemic inflammatory syndrome (MIS-C) can develop as a complication of SARS CoV-2 infection, involving the gastrointestinal system mainly by vasoconstriction, edema, glandular hyperplasia, and a procoagulant state leading to direct tissue injury. Method ology: a series of cases including 8 patients with MIS-C treated in two highly complex institutions is presented. These patients, had abdominal symptoms of surgical management. Results The average age was 9.5 years and the most frequent symptoms were fever, abdominal pain, diarrhea (100%); in addition, 87.5% presented shock. The diagnosis of SARS CoV-2 was confirmed by RT-PCR test in 37.5%, antigen 12.5% and the rest of the patients showed IgM and IgG antibodies. In laboratories, the increase in acute phase reactants, Erythrocyte Sedimentation Rate (ESR), C-reactive protein, procalcitonin, as well as troponin, D dimer and proBNP, is highlighted. The surgical outcome documented 2 patients with a normal appendix, 3 patients with edematous appendicitis, and 3 patients with complicated appendicitis. Conclusions patients with MIS-C display abdominal symptoms similar to those present in surgical emergencies and a non-negligible number of cases require surgical exploration. This condition poses a new differential diagnosis to the surgical abdomen in pediatric patients.
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Affiliation(s)
- Iván José Ardila Gómez
- Pediatric Critical Care, Colombia.,Clínica Uros, Neiva, Huila, Colombia.,Hospital Universitario Hernando Moncaleano Perdomo, Neiva, Huila, Colombia.,Professor at Universidad Surcolombiana, Neiva, Huila, Colombia
| | - Pilar Pérez López
- Pediatric Rheumatology, Colombia.,Clínica Uros, Neiva, Huila, Colombia.,Clínica Medilaser, Neiva, Huila, Colombia.,Hospital Universitario Hernando Moncaleano Perdomo, Neiva, Huila, Colombia.,Professor at Universidad Surcolombiana, Neiva, Huila, Colombia
| | - Darling Carvajal Duque
- Pediatric Critical Care, Colombia.,Hospital Universitario Hernando Moncaleano Perdomo, Neiva, Huila, Colombia.,Professor at Universidad Surcolombiana, Neiva, Huila, Colombia
| | - Doris Martha Salgado García
- Pediatric Bioethicist, Colombia.,Pediatric Infectious Diseases, Colombia.,Professor at Universidad Surcolombiana, Neiva, Huila, Colombia
| | - Andres Felipe Romero
- Pediatric Infectious Diseases, Colombia.,Clínica Uros, Neiva, Huila, Colombia.,Hospital Universitario Hernando Moncaleano Perdomo, Neiva, Huila, Colombia.,Professor at Universidad Surcolombiana, Neiva, Huila, Colombia
| | - Martha Rocío Vega Vega
- Pediatric Bioethicist, Colombia.,Hospital Universitario Hernando Moncaleano Perdomo, Neiva, Huila, Colombia.,Professor at Universidad Surcolombiana, Neiva, Huila, Colombia
| | - Jorge Andres Ramos Castañeda
- Professor at Universidad Surcolombiana, Neiva, Huila, Colombia.,MSc Clinical Epidemiology, PhD Public Health, Universidad Antonio Nariño, Neiva, Huila, Colombia
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Assa A, Benninga MA, Borrelli O, Broekaert I, de Carpi JM, Saccomani MD, Dolinsek J, Mas E, Miele E, Thomson M, Tzivinikos C; Gastrointestinal Committee of ESPGHAN. Gastrointestinal Perspective of Coronavirus Disease 2019 in Children-An Updated Review. J Pediatr Gastroenterol Nutr 2021; 73:299-305. [PMID: 34117195 DOI: 10.1097/MPG.0000000000003204] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Gastrointestinal symptoms are common findings in children with severe acute respiratory syndrome coronavirus 2 infection, including vomiting, diarrhoea, abdominal pain, and difficulty in feeding, although these symptoms tend to be mild. The hepato-biliary system and the pancreas may also be involved, usually with a mild elevation of transaminases and, rarely, pancreatitis. In contrast, a late hyper-inflammatory phenomenon, termed multisystem inflammatory syndrome (MIS-C), is characterized by more frequent gastrointestinal manifestations with greater severity, sometimes presenting as peritonitis. Gastrointestinal and hepato-biliary manifestations are probably related to a loss in enterocyte absorption capability and microscopic mucosal damage caused by a viral infection of intestinal epithelial cells, hepatocytes and other cells through the angiotensin conversion enzyme 2 receptor resulting in immune cells activation with subsequent release of inflammatory cytokines. Specific conditions such as inflammatory bowel disease (IBD) and liver transplantation may pose a risk for the more severe presentation of coronavirus disease 2019 (COVID-19) but as adult data accumulate, paediatric data is still limited. The aim of this review is to summarize the current evidence about the effect of COVID-19 on the gastrointestinal system in children, with emphasis on the emerging MIS-C and specific considerations such as patients with IBD and liver transplant recipients.
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25
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Abstract
PURPOSE OF REVIEW To review diagnosis, clinical characteristics and treatment of multisystem inflammatory syndrome in children (MIS-C) associated with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). RECENT FINDINGS MIS-C emerged in spring 2020 as a hyperinflammatory syndrome following SARS-CoV-2 exposure in children. Despite growing awareness of MIS-C, diagnosis remains challenging due to the range of phenotypes and severity. Fever accompanied by shock, cardiac dysfunction, gastrointestinal symptoms, or mucocutaneous signs suggestive of Kawasaki disease, especially in the presence of known or suspected coronavirus disease 2019 exposure, should trigger consideration of MIS-C. However, clinical presentations are highly varied and may overlap with other infectious diseases. Clinicians must maintain a high index of suspicion for MIS-C and be aware that patients may develop coronary artery aneurysms and myocarditis even with few or no Kawasaki disease symptoms. More precise diagnostic criteria and specific biomarkers are needed to aid diagnosis. Intravenous immunoglobulin (IVIG) is first-line therapy, and steroids should be considered as initial adjunctive treatment for patients with severe manifestations or other risk factors. Prompt treatment is essential, as patients may worsen acutely, though overall prognosis is reassuring. SUMMARY MIS-C associated with SARS-CoV-2 has varied clinical manifestations. Clinicians must be aware of the common presentation and potential for decompensation and cardiac sequalae to guide appropriate evaluation and treatment.
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Affiliation(s)
- Jordan E Roberts
- Division of Immunology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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26
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Manz N, Höfele-Behrendt C, Bielicki J, Schmid H, Matter MS, Bielicki I, Holland-Cunz S, Gros SJ. MIS-C-Implications for the Pediatric Surgeon: An Algorithm for Differential Diagnostic Considerations. Children (Basel) 2021; 8:children8080712. [PMID: 34438603 PMCID: PMC8393765 DOI: 10.3390/children8080712] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Revised: 08/16/2021] [Accepted: 08/17/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND multisystem inflammatory syndrome in children (MIS-C) is a new disease associated with a recent infection with severe acute respiratory syndrome coronavirus type 2 (SARS-CoV-2). Affected children can present predominantly with abdominal symptoms, fever and high inflammatory parameters that might lead to a consult by the pediatric surgeon and an indication for surgery. METHODS clinical data of three patients with MIS-C that underwent surgery were collected. Histopathological analysis of the appendix was performed. RESULTS we present the clinical course of three children with fever, abdominal pain and vomiting for several days. Clinical examination and highly elevated inflammation markers led to indication for laparoscopy; appendectomy was performed in two patients. Because of intraoperative findings or due to lack of postoperative improvement, all patients were reevaluated and tested positive for MIS-C associated laboratory parameters and were subsequently treated with corticosteroids, intravenous immunoglobulins, acetyl salicylic acid and/or light molecular weight heparin. CONCLUSIONS we discuss the implications of MIS-C as a new differential diagnosis and stress the importance of assessing the previous medical history, identifying patterns of symptoms and critically surveilling the clinical course. We implemented an algorithm for pediatric surgeons to consider MIS-C as a differential diagnosis for acute abdomen that can be integrated into the surgical workflow.
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Affiliation(s)
- Nora Manz
- Department of Pediatric Surgery, University Children’s Hospital Basel, 4056 Basel, Switzerland; (N.M.); (C.H.-B.); (I.B.); (S.H.-C.)
- Department of Clinical Research, University of Basel, 4056 Basel, Switzerland
| | - Claudia Höfele-Behrendt
- Department of Pediatric Surgery, University Children’s Hospital Basel, 4056 Basel, Switzerland; (N.M.); (C.H.-B.); (I.B.); (S.H.-C.)
| | - Julia Bielicki
- Department of Infectious Diseases, University Children’s Hospital Basel, 4056 Basel, Switzerland; (J.B.); (H.S.)
| | - Hanna Schmid
- Department of Infectious Diseases, University Children’s Hospital Basel, 4056 Basel, Switzerland; (J.B.); (H.S.)
| | - Matthias S. Matter
- Institute of Medical Genetics and Pathology, University Hospital of Basel, University of Basel, 4031 Basel, Switzerland;
| | - Isabella Bielicki
- Department of Pediatric Surgery, University Children’s Hospital Basel, 4056 Basel, Switzerland; (N.M.); (C.H.-B.); (I.B.); (S.H.-C.)
- Department of Clinical Research, University of Basel, 4056 Basel, Switzerland
| | - Stefan Holland-Cunz
- Department of Pediatric Surgery, University Children’s Hospital Basel, 4056 Basel, Switzerland; (N.M.); (C.H.-B.); (I.B.); (S.H.-C.)
- Department of Clinical Research, University of Basel, 4056 Basel, Switzerland
| | - Stephanie J. Gros
- Department of Pediatric Surgery, University Children’s Hospital Basel, 4056 Basel, Switzerland; (N.M.); (C.H.-B.); (I.B.); (S.H.-C.)
- Department of Clinical Research, University of Basel, 4056 Basel, Switzerland
- Correspondence: ; Tel.: +41-61-704-12-12
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27
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Saalabian K, Rolle U, Friedmacher F. Impact of the Global COVID-19 Pandemic on the Incidence, Presentation, and Management of Pediatric Appendicitis: Lessons Learned from the First Wave. Eur J Pediatr Surg 2021; 31:311-318. [PMID: 34161983 DOI: 10.1055/s-0041-1731295] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The fast-evolving nature of the coronavirus disease 2019 (COVID-19) pandemic has led to unprecedented clinical, logistical, and socioeconomical challenges for health-care systems worldwide. While several studies have analyzed the impact on the presentation and management of acute appendicitis (AA) in the adult population, there is a relative paucity of similar research in pediatric patients with AA. To date, there is some evidence that the incidence of simple AA in children may have decreased during the first lockdown period in spring 2020, whereas the number of complicated AA cases remained unchanged or increased slightly. Despite a worrying trend toward delayed presentation, most pediatric patients with AA were treated expediently during this time with comparable outcomes to previous years. Hospitals must consider their individual capacity and medical resources when choosing between operative and non-operative management of children with AA. Testing for severe acute respiratory syndrome coronavirus type 2 is imperative in all pediatric patients presenting with fever and acute abdominal pain with diarrhea or vomiting, to differentiate between multisystem inflammatory syndrome and AA, thus avoiding unnecessary surgery. During the further extension of the COVID-19 crisis, parents should be encouraged to seek medical care with their children early in order that the appropriate treatment for AA can be undertaken in a timely fashion.
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Affiliation(s)
- Kerstin Saalabian
- Department of Pediatric Surgery, University Hospital Frankfurt, Goethe University Frankfurt, Frankfurt (Main), Germany
| | - Udo Rolle
- Department of Pediatric Surgery, University Hospital Frankfurt, Goethe University Frankfurt, Frankfurt (Main), Germany
| | - Florian Friedmacher
- Department of Pediatric Surgery, University Hospital Frankfurt, Goethe University Frankfurt, Frankfurt (Main), Germany
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28
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Acevedo MJ, Steffey D, Dillon JE, Lee JT, Worhunsky DJ. Concurrent COVID-19 infection in children with acute appendicitis: A report of three cases. Radiol Case Rep 2021; 16:2972-2977. [PMID: 34221211 PMCID: PMC8236335 DOI: 10.1016/j.radcr.2021.06.067] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Revised: 06/18/2021] [Accepted: 06/21/2021] [Indexed: 12/28/2022] Open
Abstract
Literature describing patients with concomitant COVID-19 infection with acute appendicitis in pediatric patients is growing, and understanding the clinical picture of such patients is relevant in their treatment. We report 3 male children who were surgically treated for acute appendicitis and had concomitant SARS-CoV-2 infection. Our first patient was a 12-year-old male who presented with symptoms indicative of appendicitis but no respiratory symptoms associated with COVID-19 (eg cough, shortness of breath). Laboratory evaluation revealed leukopenia and an elevated C-reactive protein; imaging was consistent with acute appendicitis and an acute pulmonary viral infection. Though he lacked diffuse peritonitis on physical examination or a leukocytosis, he was found to have perforated appendicitis in the operating room. Our second patient was another 12-year-old male whose suspected appendicitis was confirmed via ultrasound and surgery. He tested positive for COVID-19 1 month prior and he continued to test positive for infection on admission without any associated respiratory symptoms. Our third patient was a 13-year-old patient who also presented with symptomatic acute appendicitis without apparent COVID-19 manifestations. These cases provide further examples of pediatric patients with concomitant acute appendicitis and COVID-19 infection, namely an unusual presentation of perforated appendicitis with asymptomatic COVID-19-related pulmonary infection and the more common acute appendicitis with asymptomatic COVID-19 infection.
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Affiliation(s)
- Maximo J Acevedo
- College of Medicine-NKY campus, University of Kentucky, Albright Health Center 300, 100 Grant Drive, Highland Heights, KY 41099, USA
| | - Dylan Steffey
- College of Medicine, University of Kentucky, 800 Rose Street MN 150, Lexington, KY 40506, USA
| | - Johanne E Dillon
- Department of Radiology, Division of Pediatric Radiology, University of Kentucky, Lexington, KY, USA
| | - James T Lee
- Department of Radiology, Divisions of Abdominal and Emergency Radiology, University of Kentucky, Lexington, KY, USA
| | - David J Worhunsky
- Department of Surgery, Division of Pediatric Surgery, University of Kentucky, Lexington, KY, USA
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29
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Hennon TR, Yu KOA, Penque MD, Abdul-Aziz R, Chang AC, McGreevy MB, Pastore JV, Prout AJ, Schaefer BA, Alibrahim OS, Gomez-Duarte OG, Hicar MD. COVID-19 associated Multisystem Inflammatory Syndrome in Children (MIS-C) guidelines; revisiting the Western New York approach as the pandemic evolves. Prog Pediatr Cardiol 2021; 62:101407. [PMID: 34121829 PMCID: PMC8179839 DOI: 10.1016/j.ppedcard.2021.101407] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2021] [Accepted: 06/02/2021] [Indexed: 02/06/2023]
Abstract
Multisystem inflammatory syndrome of children (MIS-C) continues to be a highly concerning diagnosis in those recently infected with SARS-CoV-2. The diagnosis of MIS-C cases will likely become even more challenging as vaccine uptake and natural immunity in previously infected persons leads to lower circulating rates of SARS-CoV-2 infection and will make cases sporadic. Febrile children presenting with cardiac dysfunction, symptoms overlapping Kawasaki disease or significant gastrointestinal complaints warrant a thorough screen in emergency departments, urgent care centers, and outpatient pediatric or family medicine practices. An increased index of suspicion and discussion regarding higher level of care (transferring to pediatric tertiary care centers or to intensive care) continues to be recommended. Herein we outline a broad approach with a multidisciplinary team for those meeting the case definition and believe such an approach is crucial for successful outcomes.
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Key Words
- AP, approved
- ASO, anti-streptolysin O
- BNP, brain-natriuretic peptide
- CDC, Center for Disease Control
- COVID-19
- COVID-19, coronavirus disease 2019
- CRP, C-reactive protein
- CXCL10, C-X-C-motif chemokine ligand 10
- DCBLD2, Discoidin, CUB and LCCL domain-containing protein 2
- E, envelope protein
- E.U., European Union
- ECMO, extracorporeal membrane oxygenation
- EKG, electrocardiogram
- EM, emergency use
- FDA, US Food and Drug Authority
- Fever
- GI, gastrointestinal
- IL, interleukin
- IVIG, intravenous immunoglobulin G
- Inflammation
- KD, Kawasaki disease
- LDH, lactate dehydrogenase
- LFTs, liver function tests
- M, membrane protein
- MIS-C
- MIS-C, Multisystem Inflammatory Syndrome in Children
- Mpred, methylprednisolone
- NP, Nucleoprotein
- PCR, polymerase chain reaction
- PT, prothrombin time
- PTT, partial thromboplastin time
- Pediatric
- RBD, receptor binding domain
- SARS-CoV-2
- TE, thromboembolic events
- TNF, tumor necrosis factor
- TWEAK, TNF-like weak inducer of apoptosis
- U.S., United States of America
- VA, veno-arterial
- VLPs, virus-like particles
- VTE, venous thromboembolic events
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Affiliation(s)
- Teresa R Hennon
- Department of Pediatrics, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, NY, United States of America.,John R. Oishei Children's Hospital, Buffalo, NY, United States of America
| | - Karl O A Yu
- Department of Pediatrics, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, NY, United States of America.,John R. Oishei Children's Hospital, Buffalo, NY, United States of America
| | - Michelle D Penque
- Department of Pediatrics, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, NY, United States of America.,John R. Oishei Children's Hospital, Buffalo, NY, United States of America
| | - Rabheh Abdul-Aziz
- Department of Pediatrics, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, NY, United States of America.,John R. Oishei Children's Hospital, Buffalo, NY, United States of America
| | - Arthur C Chang
- Department of Pediatrics, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, NY, United States of America.,John R. Oishei Children's Hospital, Buffalo, NY, United States of America
| | - Megan B McGreevy
- Department of Pediatrics, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, NY, United States of America.,John R. Oishei Children's Hospital, Buffalo, NY, United States of America
| | - John V Pastore
- Department of Pediatrics, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, NY, United States of America.,John R. Oishei Children's Hospital, Buffalo, NY, United States of America
| | - Andrew J Prout
- Wayne State University School of Medicine, Detroit, MI, United States of America.,Children's Hospital of Michigan, Detroit, MI, United States of America
| | - Beverly A Schaefer
- Department of Pediatrics, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, NY, United States of America.,John R. Oishei Children's Hospital, Buffalo, NY, United States of America
| | - Omar S Alibrahim
- Department of Pediatrics, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, NY, United States of America.,John R. Oishei Children's Hospital, Buffalo, NY, United States of America
| | - Oscar G Gomez-Duarte
- Department of Pediatrics, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, NY, United States of America.,John R. Oishei Children's Hospital, Buffalo, NY, United States of America
| | - Mark D Hicar
- Department of Pediatrics, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, NY, United States of America.,John R. Oishei Children's Hospital, Buffalo, NY, United States of America
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30
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Olmos García JM, Pareja Marín F, Martínez Bayo Á, Silvestre Beneyto R, Escrivá Tomás P. [Acute appendicitis in children with multisystemic inflammatory syndrome associated to SARS-CoV-2 (MIS-C). A complication to consider]. An Pediatr (Barc) 2021; 95:S1695-4033(21)00203-4. [PMID: 34183280 PMCID: PMC8166512 DOI: 10.1016/j.anpedi.2021.05.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 05/16/2021] [Accepted: 05/21/2021] [Indexed: 12/29/2022] Open
Affiliation(s)
| | - Fátima Pareja Marín
- Servicio de Pediatría, Hospital Mare de Déu dels Lliris, Alcoi, Alicante, España
| | - Ángela Martínez Bayo
- Servicio de Pediatría, Hospital Mare de Déu dels Lliris, Alcoi, Alicante, España
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31
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Hwang M, Wilson K, Wendt L, Pohlman J, Densmore E, Kaeppler C, Van Arendonk K, Yale S. The Great Gut Mimicker: A case report of MIS-C and appendicitis clinical presentation overlap in a teenage patient. BMC Pediatr 2021; 21:258. [PMID: 34074244 PMCID: PMC8167300 DOI: 10.1186/s12887-021-02724-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Accepted: 05/19/2021] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Abdominal pain and other gastrointestinal symptoms are common presenting features of multisystem inflammatory syndrome in children (MIS-C) and can overlap with infectious or inflammatory abdominal conditions, making accurate diagnosis challenging. CASE PRESENTATION We describe the case of a 16-year-old female who presented with clinical symptoms suggestive of appendicitis and an abdominal computed tomography (CT) that revealed features concerning for appendicitis. After laparoscopic appendectomy, histopathology of the appendix demonstrated only mild serosal inflammation and was not consistent with acute appendicitis. Her overall clinical presentation was felt to be consistent with MIS-C and she subsequently improved with immunomodulatory and steroid treatment. CONCLUSIONS We note that MIS-C can mimic acute appendicitis. This case highlights MIS-C as a cause of abdominal imaging with features concerning for appendicitis, and MIS-C should be considered in the differential for a patient with appendicitis-like symptoms and a positive COVID-19 IgG. Lab criteria, specifically low-normal white blood cell count and thrombocytopenia, appears to be of high relevance in differing MIS-C from acute appendicitis, even when appendix radiologically is dilated.
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Affiliation(s)
- Michelle Hwang
- Department of Pediatrics, Medical College of Wisconsin, Children's Corporate Center Suite 560, 999 North 92nd Street, Wisconsin, 53226, Milwaukee, USA
| | - Kelsey Wilson
- Department of Pediatrics, Medical College of Wisconsin, Children's Corporate Center Suite 560, 999 North 92nd Street, Wisconsin, 53226, Milwaukee, USA
| | - Lisa Wendt
- Department of Pediatrics, Medical College of Wisconsin, Children's Corporate Center Suite 560, 999 North 92nd Street, Wisconsin, 53226, Milwaukee, USA
| | - Joshua Pohlman
- Department of Pediatrics, Medical College of Wisconsin, Children's Corporate Center Suite 560, 999 North 92nd Street, Wisconsin, 53226, Milwaukee, USA
| | - Emily Densmore
- Department of Pediatrics, Medical College of Wisconsin, Children's Corporate Center Suite 560, 999 North 92nd Street, Wisconsin, 53226, Milwaukee, USA
| | - Caitlin Kaeppler
- Department of Pediatrics, Medical College of Wisconsin, Children's Corporate Center Suite 560, 999 North 92nd Street, Wisconsin, 53226, Milwaukee, USA
| | - Kyle Van Arendonk
- Department of Pediatrics, Medical College of Wisconsin, Children's Corporate Center Suite 560, 999 North 92nd Street, Wisconsin, 53226, Milwaukee, USA
| | - Sarah Yale
- Department of Pediatrics, Medical College of Wisconsin, Children's Corporate Center Suite 560, 999 North 92nd Street, Wisconsin, 53226, Milwaukee, USA.
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32
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Anderson JE, Campbell JA, Durowoju L, Greenberg SLM, Rice-Townsend SE, Gow KW, Avansino J. COVID-19-associated multisystem inflammatory syndrome in children (MIS-C) presenting as appendicitis with shock. J Pediatr Surg Case Rep 2021; 71:101913. [PMID: 34026490 PMCID: PMC8132508 DOI: 10.1016/j.epsc.2021.101913] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 05/11/2021] [Accepted: 05/13/2021] [Indexed: 12/29/2022] Open
Abstract
Multisystem inflammatory syndrome in children (MIS-C) is an identified complication of the COVID-19 infection. A common presentation of both COVID-19 and MIS-C is acute abdominal pain, sometimes mimicking appendicitis. We report two cases of patients initially diagnosed with appendicitis who either presented with or developed signs of shock and were found to have MIS-C. An 8-year-old girl who tested positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) reverse transcriptase-polymerase chain reaction (RT-PCR) presented with fever, abdominal pain, and shock with ultrasound findings consistent with acute appendicitis. After being treated for MIS-C, she underwent appendectomy and improved. Final pathology was consistent with acute appendicitis. A 9-year-old girl who tested negative for COVID RT-PCR presented with uncomplicated appendicitis and underwent laparoscopic appendectomy, but developed post-operative fever and shock. Antibody testing was positive and she responded to treatment for MIS-C. Histology showed lymphohistiocytic inflammation within the muscularis propria, mesoappendix and serosa without the typical neutrophil-rich inflammation and mucosal involvement of acute appendicitis. The diagnosis was MIS-C, not appendicitis. Given the new reality of the COVID-19 pandemic, pediatric surgeons must be aware of MIS-C as a possible diagnosis and should understand the diagnostic criteria and current treatment guidelines.
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Affiliation(s)
| | | | - Lindsey Durowoju
- Division of Laboratory Medicine and Pathology, Seattle Children's Hospital, PO Box 5371, Seattle, WA, 98145-5005, USA
| | | | | | - Kenneth W Gow
- Division of General and Thoracic Pediatric Surgery, USA
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33
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Valitutti F, Verde A, Pepe A, Sorrentino E, Veneruso D, Ranucci G, Orlando F, Mastrominico A, Grella MG, Mandato C. Multisystem inflammatory syndrome in children. An emerging clinical challenge for pediatric surgeons in the COVID 19 era. J Pediatr Surg Case Rep 2021; 69:101838. [PMID: 33846690 PMCID: PMC8028611 DOI: 10.1016/j.epsc.2021.101838] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Accepted: 03/06/2021] [Indexed: 12/20/2022] Open
Abstract
Background/purpose Multisystem inflammatory syndrome in children (MIS-C) is a potentially life-threatening condition occurring 2–6 weeks after Coronavirus disease 2019 (COVID-19) in previously healthy children and adolescents, characterized by clinical and laboratory evidence of multiorgan inflammation. We reported the case of a 6-year-old child presented with acute abdomen and then diagnosed with MIS-C. In addition, to better portray this new entity, we performed a systematic review of MIS-C gastrointestinal features and particularly on those mimicking surgical emergencies. Methods We described the clinical presentation, the diagnostic approach and the therapeutic outcomes of our MIS-C patient. Parallel to this, we conducted a systematic literature search using Google Scholar, PubMed, EMBASE, Scopus, focusing on gastrointestinal MIS-C. Results Our patient was initially assessed by the surgical team due to his query acute abdomen. Following the diagnosis of MIS-C with myocarditis, intravenous methylprednisolone (2 mg/Kg/day) and intravenous immunoglobulins (2 gr/Kg single infusion) were promptly started, leading to clinical improvement. According to our literature search, patients with MIS-C have a high rate of severe abdominal symptoms resembling surgical emergencies (appendicitis, obstruction, etc.) and a not negligible number of those patients have been surgically explored with variable findings. Conclusions We encourage pediatric surgeons in the upcoming months of COVID-19 pandemic to evaluate myocardial function prior to surgical abdominal exploration. In children with query acute abdomen, MIS-C should be promptly ruled out in order to avoid unnecessary surgeries that could worsen the already frail outcome of this new syndrome. Nevertheless, it should be considered that MIS-C might well encompass complications (e.g. appendicitis, segmental intestinal ischemia) which need swift surgical treatment.
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Affiliation(s)
- Francesco Valitutti
- Clinical Pediatrics and Pediatrics, University Hospital "San Giovanni di Dio e Ruggi d'Aragona", Salerno, Italy.,EBRIS (European Biomedical Research Institute of Salerno), Salerno, Italy
| | - Alessandra Verde
- Department of Traslational Medicine, University of Naples Federico II, Naples, Italy
| | - Angela Pepe
- Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", Pediatrics Section, University of Salerno, Baronissi (Salerno), Italy
| | - Eduardo Sorrentino
- Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", Pediatrics Section, University of Salerno, Baronissi (Salerno), Italy
| | - Deborah Veneruso
- Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", Pediatrics Section, University of Salerno, Baronissi (Salerno), Italy
| | - Giusy Ranucci
- Department of Pediatrics, Santobono Pausilipon Children's Hospital, Naples, Italy
| | - Francesca Orlando
- Department of Pediatrics, Santobono Pausilipon Children's Hospital, Naples, Italy
| | - Augusto Mastrominico
- Department of Pediatrics, Santobono Pausilipon Children's Hospital, Naples, Italy
| | - Mia Giovanna Grella
- Department of Pediatric Surgery, Santobono Pausilipon Children's Hospital, Naples, Italy
| | - Claudia Mandato
- Department of Pediatrics, Santobono Pausilipon Children's Hospital, Naples, Italy
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34
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Abstract
Coronavirus disease 2019 (COVID-19), caused by acute respiratory syndrome coronavirus 2 (SARS-CoV-2), is predominantly a respiratory disease. However, its significant impact on the gastrointestinal (GI) system is now well-known. SARS-CoV-2 enters cells via the angiotensin-converting enzyme-2 (ACE-2) receptor, which is abundantly expressed on lung cells, but also on enterocytes. Several etiopathogenetic mechanisms have been postulated to explain the GI involvement in COVID-19, including loss in intestinal absorption, microscopic mucosal inflammation and impaired ACE-2 function, which plays a significant role in maintaining gut homeostasis. In children the GI manifestations include anorexia, nausea, vomiting, diarrhea and abdominal pain, which may represent the earliest presenting symptoms of the disease. However, although rare, a significant GI mucosal inflammation, such as terminal ileitis mimicking an atypical appendicitis, and other GI manifestations have been reported. COVID-19 pandemic has posed a significant challenge in healthcare provision in term of ability in providing safe diagnostic procedures, face-to-face consultations, and offering comprehensive care. For instance, changes in health services have raised the risk of empirical or sub-optimal management of chronic GI disorders such as inflammatory bowel disease (IBD) due to delayed endoscopic and clinical assessment. This review will discuss the acute GI involvement in COVID-19 in children and reflect on challenges and major changes observed in clinical practice during COVID-19 pandemic by sharing both the published literature and personal experience. We also suggest potential strategies for providing optimal gastroenterology care during this unprecedented era.
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