PubMed · 14420455
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M MAMIE. 1959. [Chronic appendicitis? A case].. https://pubmed.ncbi.nlm.nih.gov/14420455/
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BACKGROUND: The importance of specific elements in the clinical diagnosis of appendicitis is controversial. This review analyses the diagnostic value of elements of disease history, clinical findings and laboratory test results in suspected appendicitis. METHODS: A systematic Medline search was made of all published studies on the clinical and laboratory diagnosis of appendicitis in patients admitted to hospital with suspected disease. Meta-analyses of receiver-operator characteristic (ROC) areas, and positive and negative likelihood ratios, of 28 diagnostic variables described in 24 studies are presented. RESULTS: Inflammatory response variables (granulocyte count, proportion of polymorphonuclear blood cells, white blood cell count and C-reactive protein concentration), descriptors of peritoneal irritation (rebound and percussion tenderness, guarding and rigidity) and migration of pain were the strongest discriminators, with ROC areas of 0.78 to 0.68. The discriminatory power of the inflammatory variables was particularly strong for perforated appendicitis, with ROC areas of 0.85 to 0.87. Appendicitis was likely when two or more inflammatory variables were increased and unlikely when all were normal. CONCLUSION: Although all clinical and laboratory variables are weak discriminators individually, they achieve a high discriminatory power when combined. Laboratory examination of the inflammatory response, clinical descriptors of peritoneal irritation, and a history of migration of pain yield the most important diagnostic information and should be included in any diagnostic assessment.
BACKGROUND: We previously reported an appendiceal imaging protocol in which children with equivocal clinical presentations for acute appendicitis undergo ultrasonography (US) followed by computed tomography (CT). However, risk groups of children who would benefit most from imaging studies have not been established. OBJECTIVE: To define and test selective imaging guidelines to increase diagnostic accuracy and reduce unnecessary testing for children with suspected appendicitis. METHODS: We modeled outcomes under 3 different management guidelines. Patients were risk-stratified by a recursive partitioning analysis of a retrospective cohort. Subjects included children with equivocal presentations of acute appendicitis evaluated between January 1996 and December 1999. By using recursive partitioning, 3 risk groups were identified: low, medium, and high risk for acute appendicitis. Three imaging guidelines were defined. Under the first guideline, representing standard clinical practice at Children's Hospital Boston at the time of the study, all children with equivocal signs and symptoms for acute appendicitis undergo US first. If the US is positive, the child proceeds to appendectomy. If the US is negative, the child undergoes CT. Under guideline 2, low-risk children undergo US and, if negative, are discharged from the hospital. High-risk children undergo CT, and medium-risk children undergo US followed by CT. Under the third guideline, low-risk children undergo no imaging and are admitted for observation. High-risk children proceed directly to appendectomy without imaging studies. Medium-risk children undergo US followed by CT. Clinical outcomes and the number of imaging studies performed were modeled under current practice and under each guideline. RESULTS: Identified were 1401 cases of equivocal appendicitis; 958 (68.4%) with complete data. The mean age was 11 +/- 4.3 years. Of 958 children, 588 (61.4%) had acute appendicitis. One hundred forty-three patients were in the low-risk group, defined as neutrophils 67%, white blood cell count >10,000/mm(3), guarding, and abdominal pain >13 hours. Of these, 202 (90%) had appendicitis. Under guideline 1, there were 22 negative appendectomies, 35 missed or delayed diagnoses, and 958 USs and 673 CT scans performed. Under guideline 2, there would have been 23 negative appendectomies, 36 missed or delayed diagnoses, and 733 USs and 637 CT scans performed. Under guideline 3, there would have been 36 negative appendectomies, 37 missed or delayed diagnoses, and 590 USs and 412 CT scans performed. CONCLUSIONS: Selective imaging guidelines can reduce the number of radiographic studies performed with minimal diminution in accuracy of diagnosis of pediatric appendicitis.
Neonatal appendicitis (NA) is a very rare surgical condition. The aim of this study is to once again draw attention to this subject by collecting our cases with NA and cases of NA reported separately in English-language literature over the period from 1901 to 2000. We performed a retrospective chart review of patients admitted to our hospital, with the clinical diagnosis of NA from 1990 to 2000. A survey of the English-language literature together with our own 7 cases revealed a total of 141 cases of NA during the period of 1901-2000. 128 cases had sufficient information for analysis. The patients are grouped and discussed according to these 3 time- periods: 1901-1975, 1976-1984 and 1985-2000. The incidence, etiology, and presenting signs and symptoms of appendicitis in newborns are discussed. Despite the similar perforation rates in the 3 time- periods (73%, 70%, 82%), mortality rate in NA has decreased from 78% in the 1901-1975 period, to 33% in the 1976-1984 period, and to 28% in the 1985-2000 period. A newborn baby presenting with continuous vomiting, refusal to feed, and, showing signs of pain through irritability, restlessness, sleep disturbance, and a distended abdomen; one should strongly suspect an abdominal disorder, perhaps appendicitis.