Article

Does this child have appendicitis?

Department of Surgery, Duke University, Durham, North Carolina, United States
JAMA The Journal of the American Medical Association (Impact Factor: 30.39). 08/2007; 298(4):438-51. DOI: 10.1001/jama.298.4.438
Source: PubMed

ABSTRACT Evaluation of abdominal pain in children can be difficult. Rapid, accurate diagnosis of appendicitis in children reduces the morbidity of this common cause of pediatric abdominal pain. Clinical evaluation may help identify (1) which children with abdominal pain and a likely diagnosis of appendicitis should undergo immediate surgical consultation for potential appendectomy and (2) which children with equivocal presentations of appendicitis should undergo further diagnostic evaluation.
To systematically assess the precision and accuracy of symptoms, signs, and basic laboratory test results for evaluating children with possible appendicitis.
We searched English-language articles in MEDLINE (January 1966-March 2007) and the Cochrane Database, as well as physical examination textbooks and bibliographies of retrieved articles, yielding 2521 potentially relevant articles.
Studies were included if they (1) provided primary data on children aged 18 years or younger in whom the diagnosis of appendicitis was considered; (2) presented medical history data, physical examination findings, or basic laboratory data; and (3) confirmed or excluded appendicitis by surgical pathologic findings, clinical observation, or follow-up. Of 256 full-text articles examined, 42 met inclusion criteria.
Twenty-five of 42 studies were assigned a quality level of 3 or better. Data from these studies were independently extracted by 2 reviewers.
In children with abdominal pain, fever was the single most useful sign associated with appendicitis; a fever increases the likelihood of appendicitis (likelihood ratio [LR], 3.4; 95% confidence interval [CI], 2.4-4.8) and conversely, its absence decreases the chance of appendicitis (LR, 0.32; 95% CI, 0.16-0.64). In select groups of children, in whom the diagnosis of appendicitis is suspected and evaluation undertaken, rebound tenderness triples the odds of appendicitis (summary LR, 3.0; 95% CI, 2.3-3.9), while its absence reduces the likelihood (summary LR, 0.28; 95% CI, 0.14-0.55). Midabdominal pain migrating to the right lower quadrant (LR range, 1.9-3.1) increases the risk of appendicitis more than right lower quadrant pain itself (summary LR, 1.2; 95% CI, 1.0-1.5). A white blood cell count of less than 10,000/microL decreases the likelihood of appendicitis (summary LR, 0.22; 95% CI, 0.17-0.30), as does an absolute neutrophil count of 6750/microL or lower (LR, 0.06; 95% CI, 0.03-0.16). Symptoms and signs are most useful in combination, particularly for identifying children who do not require further evaluation or intervention.
Although the clinical examination does not establish a diagnosis of appendicitis with certainty, it is useful in determining which children with abdominal pain warrant immediate surgical evaluation for consideration of appendectomy and which children may warrant further diagnostic evaluation. More child-specific, age-stratified data are needed to improve the utility of the clinical examination for diagnosing appendicitis in children.

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    • "Appendicitis is the most common surgical condition of childhood, accounting for 5%–10% of all pediatric emergency department visits [1] [2] [3] [4]. Timely and accurate diagnosis is critical since symptom duration is associated with perforation, which increases length of stay, complications , and hospital costs [5] [6] [7]. "
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    ABSTRACT: There are safety concerns about the use of radiation-based imaging (computed tomography [CT]) to diagnose appendicitis in children. Factors associated with CT use remain to be determined. For patients ≤18years old undergoing appendectomy, we evaluated diagnostic imaging performed, patient characteristics, hospital type, and imaging/pathology concordance (2008-2012) using data from Washington State's Surgical Care and Outcomes Assessment Program. Among 2538 children, 99.7% underwent pre-operative imaging. 52.7% had a CT scan as their first study. After adjustment, age >10years (OR 2.9 (95% CI 2.2-4.0), Hispanic ethnicity (OR 1.7, 95% CI 1.5-1.9), and being obese (OR 1.7, 95% CI 1.4-2.1) were associated with CT use first. Evaluation at a non-children's hospital was associated with higher odds of CT use (OR 7.9, 95% CI 7.5-8.4). Ultrasound concordance with pathology was higher for males (72.3 vs. 66.4%, p=.03), in perforated appendicitis (75.9 vs. 67.5%, p=.009), and at children's hospitals compared to general adult hospitals (77.3 vs. 62.2%, p<.001). CT use has decreased yearly statewide. Over 50% of children with appendicitis had radiation-based imaging. Understanding factors associated with CT use should allow for more specific QI interventions to reduce radiation exposure. Site of care remains a significant factor in radiation exposure for children. Copyright © 2015 Elsevier Inc. All rights reserved.
    Journal of Pediatric Surgery 04/2015; 50(4):642-646. DOI:10.1016/j.jpedsurg.2014.09.080 · 1.31 Impact Factor
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    • "One important exception between diabetic and nondiabetic children was that most of the diabetic children in our series did not present with fever. This finding is corroborated by the 1988 report [11] and is distinctly different from what other investigators have reported regarding appendicitis in the pediatric population [7]. It is not clear why the diabetic children in our study so infrequently presented with fever. "
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    ABSTRACT: Purpose: Children with diabetes mellitus (DM) who develop acute appendicitis can present a diagnostic and clinical challenge. No studies have examined this population since the advent of multiple dose insulin therapy, computed tomography, and laparoscopic surgery. We sought to characterize these children to identify their differences and how to best care for them. Methods: We retrospectively examined the medical records of children with a preexisting diagnosis of DM treated for acute appendicitis. Values are presented as the mean +/- the standard error of the mean, and Student's t-test was used for statistical comparison. Results: We identified 18 diabetic children treated for acute appendicitis, making this the largest series of its kind. These children had similar presentations compared to non-diabetics, with the exception of often presenting without fever (83.3% with an initial temperature <38 C). All children developed significant postoperative hyperglycemia (average high 382 +/- 18 mg/dL), and most had glycemic control for <= 50% of the hospitalization (14/ 18, 77.8%), but they otherwise had typical postoperative courses. Conclusions: Diabetic children with appendicitis are often afebrile at presentation and have serum glucose levels that are difficult to control. Collaboration with pediatric endocrinologists is needed to appropriately manage these children during their hospitalization.
    Journal of Pediatric Surgery 10/2014; 49(12). DOI:10.1016/j.jpedsurg.2014.09.003 · 1.31 Impact Factor
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    • "However, despite intensive research and discussion, rapid, accurate diagnosis of pediatric appendicitis remains an elusive challenge [2] [3] [4]. A clinical decision to operate leads to the removal of a normal appendix in 10% to 20% of the cases [5] [6]. Although diagnostic imaging has been used with increasing frequency, it has limitations such as exposure to ionizing radiation, availability of skilled technicians at all hours, and high costs [7] [8]. "
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    ABSTRACT: This study aimed to determine whether routine urinalysis may serve as a tool in discriminating between acute appendicitis and perforated appendicitis in children. We prospectively collected 357 patients with clinically suspected acute appendicitis. Urinalysis was performed in patients with clinically suspected acute appendicitis before surgical intervention. Routine urinalysis is composed of 2 examinations: chemical tests for abnormal chemical constituents and microscopic tests for abnormal insoluble constituents. Receiver operating characteristic curves for urine white blood cell (WBC) counts and urine red blood cell (RBC) counts in distinguishing between patients with simple appendicitis and patients with perforated appendicitis were also analyzed. Urine ketone bodies, leukocyte esterase, specific gravity, pH, WBC, and RBC counts were all significant parameters among patients with normal appendices, simple appendicitis, and perforated appendicitis (all P < .05). Based on multivariate logistic regression analysis, positive urine ketone bodies and nitrate were significant parameters in predicting perforated appendicitis (P = .002 and P = .008, respectively). According to the results of receiver operating characteristic curves, the appropriate cutoff values were 2.0/high-power field for urine RBC counts and 4.0/high-power field for urine WBC counts in predicting perforated appendicitis in children. Routine urinalysis may serve to aid in discriminating between simple and perforated appendicitis. Clinically, we believe that these urine parameters may aid primary emergency physicians with decision making in patients with clinically suspected appendicitis.
    The American journal of emergency medicine 09/2013; 31(11). DOI:10.1016/j.ajem.2013.06.027 · 1.15 Impact Factor
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