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PubMed2000

Abdominal pain and appendicitis: is there a difference in referrals between HMO pediatricians and private pediatricians?

BACKGROUND: In the last few years, there have been many reports of the rising incidence of late appendicitis and perforated appendicitis. The rise of managed care medicine has been blamed for this, because the health maintenance organizations (HMO) and gatekeepers allegedly want to keep the child away from the surgeon and hospital to save costs. METHODS: The authors were in a unique position a number of years ago because they had only a single HMO in their area of practice (New Brunswick, NJ) employing 14 pediatricians, and 86 pediatricians were in private practice or on the medical school staff. The HMO had a yearly contract with the pediatric surgeons, and all visits and surgeries were covered by a yearly agreement (capitated agreement). The authors compared the number of children with appendicitis, perforated appendicitis, or just abdominal pain (not requiring surgery), between both groups over a 5-year period (1991 to 1996). RESULTS: A total of 492 patients were referred with abdominal pain over a 5-year period. Two hundred eight (42%) had appendicitis, and 284 (58%) had just abdominal pain and eventually were sent home. The HMO pediatricians diagnosed appendicitis accurately in 46% of their patients (55 of 118), and 54% were abdominal pain that was not appendicitis (63 of 118). For the private pediatricians, the percentages were: 40% of their patients had appendicitis (153 of 374), and 60% had abdominal pain without appendicitis (221 of 374). The incidence of perforated appendicitis was similar (28% HMO v 30% private), and the incidence of negative explorations were similar (8% HMO v 9% private). CONCLUSIONS: The results are very similar in both groups, with a similar percentage of abdominal pain not being appendicitis (60% v 54%). HMO patients did not pay for consultations, and the HMO was not charged for any consultations. However, it does not appear that they overused the consultations for abdominal pain that were not appendicitis. Their accuracy for correct diagnosis of appendicitis was similar to the private group (46% v 40%), and the incidence of perforated appendicitis for both groups was 28% to 30%. The authors cannot draw any conclusions from their experience that HMOs in general do refer patients to surgeons in a timely fashion, and do not delay the referrals to avoid the cost of consultation, because the authors had a capitated agreement with their HMO, and consultations were free. Both groups of pediatricians, the HMO and the private pediatricians, did not realize financial gain or loss by sending children to the pediatric surgeon and were not penalized by sending patients with abdominal pain to the surgeon. On the contrary, their referral habits and judgments were similar and did not appear to change by being part of an HMO.

Abdominal Pain↗
PubMedDate not supplied

The role of serum inflammatory markers in acute appendicitis and their success in preventing negative laparotomy.

Improving the diagnosis of acute appendicitis in order to prevent unnecessary surgery is crucial. This study was intended to identify the role of serum inflammatory markers in patients with preliminary diagnosis of acute appendicitis with a retrospective design. Eighty-five patients with the preliminary diagnosis of acute appendicitis were recruited in this study within the period of November-December 2003. The average age was 31.8 years (ranged from 15 to 85). There were 62 males (72.9%) and 23 females (27.1%). In addition to performing routine tests, preoperative serum samples were obtained from the patients to measure C-reactive protein, interleukin-6, and interleukin-10. All the patients were operated on for a clinical suspicion of acute appendicitis. Depending on the macroscopic evidence during the operation and the histopathological examination of the specimen, the patients were separated into two groups: the ones who did not have acute appendicitis as the cause for acute abdomen (group I; n = 14) and the ones who had acute appendicitis (group II; n = 71). The ones who had acute appendicitis (group II) were further grouped as noncomplicated appendicitis (group IIA; n = 44) and complicated appendicitis (group IIB; n = 27). Being a male with elevated levels of leukocytes (white blood cells, WBC); C-reactive protein (CRP), interleukin-6 (IL-6); and interleukin-10 increased the probability of having acute appendicitis in patients with evidences of acute abdomen. The risk of complication of acute appendicitis significantly increased when patients had increased levels of C-reactive protein, increased erythrocyte sedimentation rate, and increased interleukin-6 levels, had symptoms for more than 24 h, and were female. Interleukin-10 levels within normal range might be helpful in eliminating the possibility of acute appendicitis. Thus, elevated levels of WBC, IL-6 and CRP might be helpful in confirming a potential diagnosis of acute appendicitis. In addition, normal levels of IL-10 might be of additional help to possibly rule out the diagnosis of acute appendicitis.

Abdominal Abscess↗
PubMed2003

Ovoid shape of the vermiform appendix: a criterion to exclude acute appendicitis--evaluation with US.

PURPOSE: To investigate whether the shape of the appendix in transverse section may be considered an ultrasonographic (US) criterion to exclude or confirm acute appendicitis. MATERIALS AND METHODS: The shapes of appendices of 100 control subjects, of 174 patients with clinical suspicion of acute appendicitis but without acute appendicitis, and of 108 patients with acute appendicitis were prospectively evaluated with US. Definite diagnoses in patients with clinical suspicion of acute appendicitis were established and confirmed either with surgery and histologic examination in 161 patients or with clinical follow-up in 121 patients. Statistical measures such as sensitivity, specificity, positive and negative predictive values, and accuracy were assessed for the appendiceal shape as a diagnostic US criterion for acute appendicitis. RESULTS: An at least partly round appendix indicated acute appendicitis with a sensitivity of 100%; specificity of 37%; positive and negative predictive values of 50% and 100%, respectively; and accuracy of 61%. In 67 of 174 patients with clinical suspicion of acute appendicitis but without acute appendicitis, the partly ovoid appendiceal shape aided in the exclusion of acute appendicitis, since it indicated a normal appendix with a probability of 86%. In 65 of 174 patients with clinical suspicion of acute appendicitis but without acute appendicitis, the ovoid shape over the entire appendiceal length excluded acute appendicitis with confidence. CONCLUSION: The shape of the appendix in transverse section is a useful US criterion, since an ovoid shape over the entire appendiceal length reliably rules out acute appendicitis.

Acute Disease↗
PubMed2002

[Diagnosis of appendicitis with particular consideration of the acupuncture point Lanwei--a prospective study].

BACKGROUND: In almost all Western industrial nations, appendicitis is the most frequent cause for acute abdomen. Nevertheless, the diagnosis of appendicitis is often difficult, which manifests in highly negative laparotomy rates. In a prospective study we aimed to investigate if palpation of the acupuncture point Lanwei (extra point 22, extra point 33) which is located on the right leg may increase the accuracy in the diagnosis of appendicitis. PATIENTS AND METHODS: Presurgically, the Lanwei point was examined for reproducible tenderness on 116 cooperative nonanesthetized patients admitted to hospital for suspected appendicitis. The results were compared with those of histological diagnosis. The examination of tenderness of the Lanwei sign was performed without knowing the results of other examinations. Additionally, other signs and laboratory parameters for appendicitis were examined using a standardized documentation form. Altogether, 17 presurgical variables, 18 clinical signs, and 3 tests were evaluated. RESULTS: A positive Lanwei sign was documented in 65 cases (56%), whereas 51 patients (44%) had a negative Lanwei sign. 65 of the 116 patients were operated. 59 of those had a histologically proven appendicitis. The sensitivity of the Lanwei sign was 64.4%, specificity ranged at 50%. Rates for positive and negative predictive values were 92.7% and 12.5%, respectively. Odds ratio was estimated as 1.8. When comparing these parameters, the Lanwei sign ranged between the 7th and 10th place of the 22 most important clinical signs for appendicitis. The negative laparotomy rate was 9%, of which 4 of 6 patients had other indications for an operation. The rate of perforation was 15%. CONCLUSION: Compared with many conventional signs for appendicitis as for example Mc Burney, tender Sherren triangle, reduced peristalsis, the diagnostic value of the Lanwei sign is not sufficient. Although a reproducible positive Lanwei sign is a good hint for a true appendicitis, in case of a negative Lanwei sign the probability for an appendicitis may be relatively high. Because of the low negative predictive value, the Lanwei sign is not suitable for reducing negative laparatomy rates. As in many other studies, the one and only indicator for appendicitis which yields high results in all statistical parameters was not detected in this study. In comparison to the statistical parameters of traditional signs for appendicitis, the Lanwei sign cannot be regarded as a good diagnostic parameter for appendicitis.

Acupuncture Points↗
PubMed2006

Atypical clinical features of pediatric appendicitis.

BACKGROUND: The diagnosis of appendicitis remains challenging in children. Delays in diagnosis, or misdiagnosis, have important medical and legal implications. The typical, or classic, presentation of pediatric appendicitis has been modeled after adult disease; however, many children present atypically with subtle findings or unusual signs. OBJECTIVES: To determine the frequency of atypical clinical features among pediatric patients with appendicitis and to investigate which atypical features are the strongest negative predictors for appendicitis among patients being evaluated for appendicitis. METHODS: Children and adolescents with suspected appendicitis were enrolled over 20 consecutive months. Pediatric emergency physicians completed standardized data collection forms on eligible patients. Final diagnosis was determined by pathology or follow-up telephone call. Typical and atypical findings were defined strictly a priori. RESULTS: Seven hundred fifty-five patients were enrolled. The median age was 11.9 years (interquartile range [IQR]: 8.5, 14.9 yr); 36% of patients were diagnosed with appendicitis. Among patients with appendicitis, the most common atypical features included absence of pyrexia (83%), absence of Rovsing's sign (68%), normal or increased bowel sounds (64%), absence of rebound pain (52%), lack of migration of pain (50%), lack of guarding (47%), abrupt onset of pain (45%), lack of anorexia (40%), absence of maximal pain in the right lower quadrant (32%), and absence of percussive tenderness (31%). Forty-four percent of patients with proven appendicitis had six or more atypical characteristics. The median number of atypical features for patients with proven appendicitis was five (IQR: 4.0, 7.0). The greatest negative predictors, on the basis of likelihood ratios, were as follows: white blood cell count (WBC) of <10,000 per cubic millimeter (likelihood ratios [LR], 0.18), absolute neutrophil count (ANC) of <7,500 per cubic millimeter (LR, 0.35), lack of percussive tenderness (LR, 0.50), lack of guarding (LR, 0.63), and no nausea or emesis (LR, 0.65). CONCLUSIONS: Appendicitis in pediatric patients is difficult to diagnose because children present with a wide variety of atypical clinical features. Forty-four percent of patients with appendicitis presented with six or more atypical features. Two atypical features are the strongest negative predictors of appendicitis in children: WBC of <10,000 per cubic millimeter and an ANC of <7,500 per cubic millimeter.

Adolescent↗
PubMed2007

The natural history and traditional management of appendicitis revisited: spontaneous resolution and predominance of prehospital perforations imply that a correct diagnosis is more important than an early diagnosis.

BACKGROUND: The principle of early exploration on wide indications in order to prevent perforation has been the guiding star for the management of patients with suspected appendicitis for over 100 years, dating back to a time when appendicitis was a significant cause of mortality. Since then there has been a dramatic decrease in mortality due to appendicitis. Emerging evidence calls for a new understanding of the natural history of untreated appendicitis. This motivates a reappraisal of the fundamental principles for the management of patients with suspected appendicitis. METHODS: Analysis of epidemiologic and clinical studies that elucidate the natural history of appendicitis, i.e. the possibility of spontaneous resolution or the risk of progression to perforation, the determinants of the proportion of perforations and mortality, and the consequence of in-hospital delay. RESULTS: The results presented in a number of studies suggest that spontaneous resolution of appendicitis is common, that perforation can seldom be prevented, that the risk of perforation has been exaggerated and that in-hospital delay is safe. An alternative understanding of the inverse relationship between the proportion of negative explorations and perforation and the increasing proportion of perforation with length of time is presented, mainly explaining these findings by selection due to spontaneous resolution. CONCLUSION: Evidence suggests that spontaneous resolution of untreated, non-perforated appendicitis is common and that perforation can rarely be prevented and is associated with a lower increase in mortality than was previously thought. This motivates a shift in focus from the prevention of perforation to the early detection and treatment of advanced appendicitis. In order to minimize mortality, morbidity and costs avoidance of negative appendectomies is more important then preventing perforation. In patients with an equivocal diagnosis where advanced appendicitis is deemed less likely a correct diagnosis is more important than a rapid diagnosis. These patients can safely be managed by active observation with an improved diagnostic work-up under observation, which has consistently shown a low proportion of negative appendectomies without an increase in the proportion of perforations or morbidity. A high proportion of perforations can be explained by selection due to undiagnosed resolving appendicitis. The proportion of perforation is therefore a questionable measure of the quality of the management of patients with suspected appendicitis and should be used with caution.

Appendectomy↗
PubMed2006

Laparoscopic appendectomy is a favorable alternative for complicated appendicitis in children.

Laparoscopic appendectomy in children is a generally accepted procedure for the treatment of non-complicated acute appendicitis. Nevertheless, the role of laparoscopy in complicated appendicitis is more controversial. The objective of this study was to examine the safety, efficacy and complications of laparoscopy in children with complicated appendicitis. This is a retrospective review of the children who underwent laparoscopic appendectomy for complicated appendicitis at King Khalid University Hospital, Riyadh, Saudi Arabia between January 1998 and March 2006. Complicated appendicitis includes perforated appendicitis, gangrenous appendicitis and appendicular masses found intra-operatively. Data collected include demographic, duration of symptoms, operative time, analgesia, complications, length of hospitalization and histopathology. Laparoscopic appendectomy was done by three trocar technique in all cases. During the study period, 59 children aged 3-12 years underwent laparoscopic appendectomy for complicated appendicitis. There were 34 patients with perforated appendicitis, 12 patients with gangrenous appendicitis and 13 patients with appendicular mass. The average operating time was 62 min. The average length of hospitalization was 5 days. The post-operative narcotic analgesic requirement was minimal. Laparoscopy was converted to open surgery in two patients (3.38%). These two cases were excluded from further analysis. Four out of 57 patients (7.01%) had post-operative complications. Three patients (5.26%) developed wound infection. One patient (1.75%) developed haematoma at umbilical port site. There was no post-operative intra-abdominal collection. Laparoscopic appendectomy is a safe alternative for the treatment of complicated appendicitis. It does not increase the incidence of complications even with complicated appendicitis. Contrary to the previous studies, we did not have increased incidence of intra-abdominal collection in this review. However, prospective randomized controlled trials are needed to verify these findings.

Appendectomy↗
PubMed1999

A fertile-aged woman with right lower abdominal pain but unelevated leukocyte count and C-reactive protein. Acute appendicitis is very unlikely.

BACKGROUND AND AIMS: An uninflamed appendix at appendectomy represents a misdiagnosis. In fertile-aged women, the diagnostic accuracy in acute appendicitis is usually lower than 60%. We studied the role of preoperative leukocyte count and C-reactive protein (CRP) measurements in the diagnosis of acute appendicitis in fertile-aged women with a clinical suspicion of acute appendicitis. In particular, what is the clinical value of unelevated leukocyte count and CRP in excluding acute appendicitis in these patients? METHODS: We calculated the mean leukocyte count and CRP values in (1) 100 consecutive fertile-aged women operated on for a clinical suspicion of acute appendicitis but with an uninflamed appendix found at appendectomy, and (2) 100 consecutive fertile-aged women operated on for a clinical suspicion of acute appendicitis and acute appendicitis found at appendectomy. The percentages of patients with (1) both values unelevated, (2) only leukocyte count elevated, (3) only CRP value elevated, or (4) both values elevated were calculated within the groups A (uninflamed appendix) and B (acute appendicitis). RESULTS: The mean leukocyte value was significantly (P<0.001) higher in patients with acute appendicitis (13.7x10(9)/l) than in those with an uninflamed appendix (10.6x10(9)/l). Similarly, the mean CRP value was significantly (P<0.05) higher in patients with acute appendicitis (42 mg/l) than in those with an uninflamed appendix(29 mg/l). Taken together, 24 patients were operated on for a clinical suspicion of acute appendicitis, although preoperative leukocyte count and CRP values were unelevated. An uninflamed appendix was found in all these patients at appendectomy. CONCLUSION: Although clinical symptoms and signs indicated acute appendicitis, unelevated leukocyte count and CRP values excluded it, with a 100% predictive value in the current study of fertile-aged women. In our patients, 24% (24 of 100) of unnecessary appendectomies could have been avoided by trusting in this finding.

Abdominal Pain↗
PubMed2006

Laparoscopic appendectomy significantly reduces length of stay for perforated appendicitis.

INTRODUCTION: Though ruptured appendicitis is not a contraindication to laparoscopic appendectomy (LA), most surgeons have not embraced LA as the first-line approach to ruptured appendicitis. In fact, in 2002, the Cochrane Database Review concluded: 1) the clinical effects of LA are "small and of limited clinical relevance," and 2) the effects of LA in perforated appendicitis require further study. OBJECTIVE: To study the effects of LA vs open appendectomy (OA) among adults with appendicitis. METHODS: In 2003, 272 adults underwent appendectomy at a large County hospital, and were enrolled in a prospective clinical pathway that detailed their hospital course from time of diagnosis to discharge. Data included patient demographics, time elapse from diagnosis to surgery, surgical technique (LA vs. OA), operative diagnosis (acute vs perforated appendicitis) and post-operative length of stay (LOS). RESULTS: Complete data was obtained for 264 (97%) patients. Patient demographics were similar in the LA and OA groups (p > 0.05). Patients with LA had a significantly shorter LOS than OA by 1.6 days (p < 0.05). This LOS was significantly shorter among those with ruptured appendicitis vs. non-ruptured appendicitis (2.0 days vs. 0.3 day reduction, p = 0.0357). Rank-order multiple regression analysis, controlling for all other factors, showed laparoscopy to have a significant effect on postoperative LOS in all appendicitis cases, especially ruptured appendicitis. CONCLUSIONS: The two-day reduction in LOS among those with ruptured appendicitis who underwent LA was significant enough to overcome the smaller benefit of LA in acute appendicitis. From a hospital utilization point of view, LA should be considered as the first-line approach for all patients with appendicitis.

Adult↗
PubMed2002

The role of colonoscopy in the diagnosis of appendicitis in patients with atypical presentations.

BACKGROUND: Acute appendicitis is one of the most common causes of acute abdomen. Despite recent advances in radiologic imaging, the diagnosis of acute appendicitis may be difficult on occasion. The aims of this study were to describe the colonoscopic features of appendicitis and to determine whether colonoscopy can be used as an adjunct for the diagnosis of appendicitis in patients with atypical presentations. METHODS: The colonoscopic findings in 21 patients (14 men, 7 women; average age 55 years) with a colonoscopic or histopathologic diagnosis of appendicitis were analyzed retrospectively. Colonoscopy was performed because diagnoses suggested by CT were other than acute appendicitis (11 patients), and/or the presenting clinical features were atypical for acute appendicitis with the duration of symptoms being 10 days or longer (17 patients). RESULTS: The colonoscopic diagnosis was acute appendicitis for all 21 patients. Seventeen underwent appendectomy, the diagnosis being verified in all cases. Of the 4 patients whose symptoms improved without appendectomy, 3 were considered to have acute appendicitis because pus was seen to drain from the appendiceal orifice at colonoscopy. A definite diagnosis could not be made in the remaining 1 patient. Therefore, the diagnosis of appendicitis was considered confirmed in 20 of 21 patients. Colonoscopic findings in these 20 patients included hyperemia (15) and bulging (18) at the appendiceal orifice area with surrounding mucosal edema (19), and drainage of pus from the appendiceal orifice (7). CONCLUSION: Colonoscopy may be useful in the diagnosis of appendicitis when the clinical presentation is atypical for appendicitis and/or imaging studies are nondiagnostic.

Abdomen, Acute↗
PubMed2000

False-negative and false-positive errors in abdominal pain evaluation: failure to diagnose acute appendicitis and unnecessary surgery.

OBJECTIVES: To test the hypothesis that physician errors (failure to diagnose appendicitis at initial evaluation) correlate with adverse outcome. The authors also postulated that physician errors would correlate with delays in surgery, delays in surgery would correlate with adverse outcomes, and physician errors would occur on patients with atypical presentations. METHODS: This was a retrospective two-arm observational cohort study at 12 acute care hospitals: 1) consecutive patients who had an appendectomy for appendicitis and 2) consecutive emergency department abdominal pain patients. Outcome measures were adverse events (perforation, abscess) and physician diagnostic performance (false-positive decisions, false-negative decisions). RESULTS: The appendectomy arm of the study included 1, 026 patients with 110 (10.5%) false-positive decisions (range by hospital 4.7% to 19.5%). Of the 916 patients with appendicitis, 170 (18.6%) false-negative decisions were made (range by hospital 10.6% to 27.8%). Patients who had false-negative decisions had increased risks of perforation (r = 0.59, p = 0.058) and of abscess formation (r = 0.81, p = 0.002). For admitted patients, when the inhospital delay before surgery was >20 hours, the risk of perforation was increased [2.9 odds ratio (OR) 95% CI = 1.8 to 4.8]. The amount of delay from initial physician evaluation until surgery varied with physician diagnostic performance: 7.0 hours (95% CI = 6.7 to 7.4) if the initial physician made the diagnosis, 72.4 hours (95% CI = 51.2 to 93.7) if the initial office physician missed the diagnosis, and 63.1 hours (95% CI = 47.9 to 78.4) if the initial emergency physician missed the diagnosis. Patients whose diagnosis was initially missed by the physician had fewer signs and symptoms of appendicitis than patients whose diagnosis was made initially [appendicitis score 2.0 (95% CI = 1.6 to 2.3) vs 6.5 (95% CI = 6.4 to 6.7)]. Older patients (>41 years old) had more false-negative decisions and a higher risk of perforation or abscess (3.5 OR 95% CI = 2.4 to 5.1). False-positive decisions were made for patients who had signs and symptoms similar to those of appendicitis patients [appendicitis score 5.7 (95% CI = 5.2 to 6.1) vs 6.5 (95% CI = 6.4 to 6.7)]. Female patients had an increased risk of false-positive surgery (2.3 OR 95% CI = 1.5 to 3.4). The abdominal pain arm of the study included 1,118 consecutive patients submitted by eight hospitals, with 44 patients having appendicitis. Hospitals with observation units compared with hospitals without observation units had a higher "rule out appendicitis" evaluation rate [33.7% (95% CI = 27 to 38) vs 24.7% (95% CI = 23 to 27)] and a similar hospital admission rate (27.6% vs 24.7%, p = NS). There was a lower miss-diagnosis rate (15.1% vs 19.4%, p = NS power 0.02), lower perforation rate (19.0% vs 20.6%, p = NS power 0.05), and lower abscess rate (5.6% vs 6.9%, p = NS power 0.06), but these did not reach statistical significance. CONCLUSIONS: Errors in physician diagnostic decisions correlated with patient clinical findings, i.e., the missed diagnoses were on appendicitis patients with few clinical findings and unnecessary surgeries were on non-appendicitis patients with clinical findings similar to those of patients with appendicitis. Adverse events (perforation, abscess formation) correlated with physician false-negative decisions.

Abdominal Pain↗
PubMed2004

The diagnosis of appendicitis in children: outcomes of a strategy based on pediatric surgical evaluation.

OBJECTIVE: To determine the accuracy of a protocol for diagnosis of appendicitis in children based on clinical evaluation by a pediatric surgeon with selective use of diagnostic imaging studies. We performed this study because 1) current reports in the medical, pediatric, emergency medical, and surgical literature advocate imaging, particularly computed tomography (CT), as the gold standard for diagnosis of appendicitis, and 2) the value of pediatric surgical evaluation early in the management of the child with possible appendicitis has rarely been emphasized. METHODS, DESIGN, SETTING, AND PARTICIPANTS: Retrospective review of 356 children (mean age: 9.6 years; range: 1-18 years) referred to a regional pediatric surgical center for possible appendicitis from 1999 through 2001. INTERVENTIONS: Initial pediatric surgical evaluation consisted of history, physical examination, white blood cell count, differential count, and urinalysis. Children diagnosed with appendicitis underwent appendectomy without additional studies; those with equivocal findings received intravenous fluids, rest, and reevaluation after 4 to 6 hours. Imaging was used selectively by the pediatric surgeon. OUTCOME MEASURES: Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of the protocol based on final diagnoses; rate of appendiceal perforation; and rate of negative appendectomy. RESULTS: Of 356 children evaluated for appendicitis, 220 (62%) had an appendectomy. Two-hundred nine (95%) had histologically proven appendicitis, and 11 (5%) had a normal appendix. Of the 209 children with appendicitis, 139 (66%) had acute appendicitis, 34 (16%) had advanced appendicitis without perforation, and 36 (17%) had advanced appendicitis with perforation. Appendectomy was performed after initial evaluation in 195 (89%) of the 220 children and after a period of supportive care and observation in 25 (11%) of 220. One hundred thirty-six children (38%) did not have an appendectomy and were discharged with other diagnoses. The sensitivity of this protocol was 99%, specificity was 92%, positive predictive value was 95%, and negative predictive value was 99%. The accuracy was 97% compared with an accuracy of 82% for ultrasound alone and 90% for CT scan alone. CONCLUSIONS: These data show that a protocol based on clinical evaluation by a pediatric surgeon with selective use of imaging was highly accurate for the diagnosis of appendicitis in children. Low rates of negative appendectomy (5%) and perforation (17%) were achieved without the potential costs and radiation exposure of excess imaging.

Adolescent↗
PubMed2003

Epidemiologic features of acute appendicitis in Ontario, Canada.

INTRODUCTION: To describe the epidemiology of acute appendicitis in the Province of Ontario, we carried out a retrospective population-based cohort study of all patients with acute appendicitis. METHODS: Using hospital discharge abstracts of patients with acute appendicitis from all acute care hospitals in Ontario for the fiscal years 1991-1998 coded for the Canadian Institute for Health Information, we studied the demographic features, particularly age and sex, length of hospital stay (LOS), incidence, and seasonal variation of acute appendicitis. RESULTS: During the observation period, 65,675 cases of acute appendicitis occurred in Ontario. Of these, 58% of the patients were male and 35.5% had perforation. The mean (and standard deviation [SD]) LOS for patients with perforation was 6.2 (5.3) days versus 3 (1.8) days for patients with no perforation (p < 0.001). The age-specific incidence of acute appendicitis followed a similar pattern for males and females, but males had higher rates in all age groups. The incidence was highest in those aged 10-19 years. The annual age and sex-adjusted incidence of acute appendicitis was 75 per 100,000 population. The female:male age-adjusted rate ratio was 1:1.4. During the study period, the rate of acute appendicitis decreased by 5.1%, but the rate of appendicitis with perforation increased by 13%. A significant seasonal effect was also observed, with the rate of acute appendicitis being higher in the summer months. CONCLUSIONS: Appendicitis is more common in males, in those aged 10-19 years, and during the summer months. The frequency of acute appendicitis appears to be decreasing whereas the proportion of cases with perforation appears to be increasing. This may reflect a change in the population structure in Ontario and restrictions placed on the patient access to the health care system.

Acute Disease↗
PubMedDate not supplied

[An useful classification for acute appendicitis].

OBJECTIVE: To analyze clinical aspects of acute appendicitis at a teaching hospital, and to present a simple classification for acute appendicitis according to surgical findings, a classification that will indicate what postoperative treatment should be. MATERIALS AND METHODS: The study included 3,112 adult patients who had undergone surgery between September 1994 and February 2000 and who had been diagnosed preoperatively with acute appendicitis. Faced with the need to simplify description of surgical findings and to relate them to treatment, the following classification was instituted: Grade 0: No appendicitis; incidental appendectomy was carried out and antimicrobians were stopped. Grade Ia: Oedematous, ingurgitated appendix. Grade Ib: Abscessed or phlegmonous appendix, presents fibrin membranes and seropurulent liquid around appendix. Grade Ic: Necrosed appendix with no perforation. In these grades, there is very little or no presence of bacteria in periappendicular liquid or in fibrin membranes. Hence, treatment consisted of appendectomy and perioperative antimicrobians (metronidazol 500 mg and amikacine 500 mg within 2 h prior to surgery, followed by two further doses every 8 h postoperatively). Grade II: Perforated appendix with localized abscess. Treatment consisted of appendectomy and antimicrobians begun preoperatively and continuing for 3 days. A Saratoga or Penrose drain was inserted if internal tissue bed remaining after excision was raw or bloody, and might have predisposed to collection of fluid. Grade III: Complicated appendicitis with generalized peritonitis. In these cases, appendectomy was carried out with lavage to abdominal cavity. Antimicrobians were administered beginning preoperatively and were continued until patient's general condition was good, the patient had remained afebrile for 48 h and white cell count had fallen. RESULTS: Patients ranged in age from 16 to 83 years, with 62% of patients men and 38%, women. Grade I appendicitis was found to be the most common, affecting 74% of patients. Hospital stay for grade I appendicitis was 2 days; for grade II appendicitis, from 2 to 7 days; and for grade III appendicitis, from 3 to 14 days. No significant difference was noted in presence of surgical wound infection among grade I appendicitis cases, incidence being 1.1%. In grade II appendicitis cases, incidence was 17.1% and 36% in grade III cases. CONCLUSIONS: Classification of acute appendicitis as herein proposed made it possible to standardize management and treatment carried out and to predict possible complications.

Acute Disease↗
PubMed2004

Which children could benefit from additional diagnostic tools in case of suspected appendicitis?

BACKGROUND: New diagnostic tools such as ultrasound scan, computed tomography (CT) scan, and diagnostic laparoscopy, have become available for children with suspected appendicitis but should be reserved for equivocal cases. The aim of this study was to develop a scoring system to identify this subgroup of children. METHODS: Patients from 2 different periods (period 1, 99 consecutive children [group 1] and period 2, 62 consecutive children [group 2] with suspected appendicitis) were prospectively evaluated. Variables predicting appendicitis were obtained from group 1. By means of a regression analysis, a scoring system was created and applied to the patients of group 2. Missed appendicitis and negative appendectomy rates obtained by clinical practice were compared with the results that would have been accomplished based on the scoring system. Thereafter, the scoring system was externally validated in a group of children presented at another hospital (group 3, n = 114). RESULTS: The variables, leukocyte count > or = 10.10(9)/L (2 points); rebound tenderness (2 points); and temperature > or = 38 degrees C (1 point) correlated significantly with appendicitis. The scoring system was used to categorize patients into 3 groups: appendicitis unlikely, doubtful appendicitis, and suspected appendicitis. The specificity and sensitivity of the scoring system were, respectively, 85% and 89%. Applying the scoring system would lead to comparable negative appendectomy rates of 8% versus 6% using clinical judgement and a comparable number of performed laparoscopies (26% v 31%). However, it could lead to a lower missed appendicitis rate (1% v 6%) and a lower perforation rate (0% v 11%). External validation showed comparable performed laparoscopies (32%) and missed appendicitis (2%) rates but a higher negative appendectomy rate (19%), probably owing to a lower percentage of appendicitis in hospital (2, 47%) compared with hospital (1, 71%). CONCLUSIONS: Children can be observed if leukocyte count is less than 10.10(9)/L and rebound tenderness is absent; a diagnostic laparoscopy should be performed if one of these is present, and if both are present one could perform an appendectomy.

Abdominal Pain↗
PubMed2002

Appendicitis: should diagnostic imaging be performed if the clinical presentation is highly suggestive of the disease?

BACKGROUND & AIMS: Our aim was to investigate whether diagnostic imaging is required if the clinical presentation suggests acute appendicitis with high probability. METHODS: On the basis of clinical findings, 350 consecutive patients with clinical suspicion of acute appendicitis were prospectively divided into 3 groups as follows: low, intermediate, and high probability of having appendicitis. All patients then underwent diagnostic ultrasonography. The clinical likelihood of appendicitis and the ultrasonographic results were correlated with the definite diagnoses. RESULTS: In the patients with clinically low probability of having appendicitis, appendicitis was present in 10% (11 of 109 patients), and, in those with intermediate probability, appendicitis was present in 24% (23 of 97 patients). Patients with clinically high probability of having appendicitis had appendicitis in 65% (94 of 144 patients), an alternative diagnosis in 18% (26 of 144 patients), and no specific definitive diagnosis in 17% (24 of 144 patients). Ultrasonography diagnosed appendicitis and the differential diagnoses with a sensitivity of 98% and 97%, specificity of 98% and 100%, positive predictive value of 96% and 99%, negative predictive values of 99% and 99%, and accuracy of 98% and 99%, respectively. CONCLUSIONS: Even in patients with clinically high probability of acute appendicitis, diagnostic imaging should be performed because it accurately depicts a high percentage of normal appendices and differential diagnoses.

Acute Disease↗
PubMed2001

Acute appendicitis in children: the importance of family history.

BACKGROUND/PURPOSE: Acute appendicitis is common, frequently atypical, challenging, and still associated with significant morbidity. Despite major technologic advances, appendicitis remains a primarily clinical diagnosis. Therefore, no relevant anamnestic information should be overlooked. Surprisingly, the relationship between heredity and appendicitis is seldom considered. Because of the potential clinical importance of the family history, the authors addressed this question prospectively over a 52-month period in a practice that includes the majority of pediatric patients with appendicitis in the region. METHODS: Family histories were obtained in a standardized manner, focusing on first-degree relatives. Children with incomplete family information were excluded. Patients (ages 2(1/2) to 19 years) were divided into 3 groups: group A, children who underwent an appendectomy (n = 166); group B (first control), children who presented with an acute abdomen and suspected appendicitis but did not undergo an appendectomy (n = 117); group C (second control), children who were seen in the practice for unrelated conditions (n = 141). RESULTS: A positive parental history was obtained from 59 patients (36%) in group A, 24 patients (21%) in group B, and 20 patients (14%) in group C, and the odds ratios (ORs) were 2.0 (P =.035) and 2.9 (P <.001) for groups A versus B and A versus C, respectively. Of the 13 patients whose sibling had had acute appendicitis, 9 were in group A versus 2 each in groups B and C, and the OR for any family history (siblings, parents) in groups A versus B was 1.9 (P =.028) and for groups A versus C was 2.9 (P < 0.001). Appendicitis was histologically confirmed in 93% of children in group A. CONCLUSIONS: Heredity is a significant factor in pediatric patients who have appendicitis. Children who have appendicitis are twice as likely to have a positive family history than are those with right lower quadrant pain (but no appendicitis) and almost 3 times as likely to have a positive family history than are surgical controls (without abdominal pain). Because of its potential value in changing the threshold for intervention, a careful family history should be obtained for every child in whom acute appendicitis is suspected.

Abdomen, Acute↗
PubMed1994

Indications for operation in suspected appendicitis and incidence of perforation.

OBJECTIVE: To clarify poorly understood epidemiological features of appendicitis. DESIGN: Retrospective study of consecutive cases from a defined population and analysis of data from published studies. SETTING: County of Jönköping, Sweden. 3029 patients who underwent operation in 1984-9 and 4717 patients from the county town who underwent operation in 1970-89, all for suspected appendicitis, plus 48,426 cases from six reported studies. MAIN OUTCOME MEASURES: Incidences specific for age and sex and temporal trends of perforating and non-perforating appendicitis and removal of a normal appendix. Associations between diagnostic accuracy, rate of perforation, and incidences of removal of a normal appendix and of perforating and non-perforating appendicitis. RESULTS: The incidence of appendicitis was 116/100,000 inhabitants. Appendicitis was more common in male patients. The incidence of perforating appendicitis was independent of age, stable over time, and uninfluenced by the rate of laparotomy, whereas the incidence of non-perforating appendicitis was age dependent, decreasing over time, and related to the diagnostic accuracy and rate of removal of a normal appendix. CONCLUSIONS: Perforating and non-perforating appendicitis seem to be separate entities, and appendicitis that resolves spontaneously is common. This may have important implications for managing suspected appendicitis.

Adolescent↗