Pediatric appendicitis or not: A retrospective cohort study from a single institution-our management and factors determining the disease

Nimmita  Srisan; Teerasak  PhewPlung; Katawaetee  Decharun; Prapapan  Rajatapiti; Paisarn  Vejchapipat

Authors

Nimmita Srisan Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, The Thai red cross society, Bangkok, Thailand
Teerasak PhewPlung Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, The Thai red cross society, Bangkok, Thailand
Katawaetee Decharun Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, The Thai red cross society, Bangkok, Thailand
Prapapan Rajatapiti Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, The Thai red cross society, Bangkok, Thailand
Paisarn Vejchapipat Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, The Thai red cross society, Bangkok, Thailand

Keywords:

Appendicitis, computed tomography, diagnosis, overnight observation, ultrasonography

Abstract

Background: Appendicitis in children is a common health problem, but its management still has some controversial aspects.

Objectives: This study aimed to assess our treatment guidelines and determine factors in differentiating children with acute appendicitis from other diseases.

Methods: Pediatric surgery consultations for suspected appendicitis from October 2019 to October 2021 was retrospectively studied. The treatment guidelines of children with suspected appendicitis were elucidated. Moreover, factors identifying the diagnosis of appendicitis were analyzed using multi-variate logistic regression.

Results: Ninety-one children were consulted for suspected appendicitis. Forty-one children (45.1%) were promptly successfully treated without observation or ultrasonography, except one negative appendectomy (2.4%). The other 50 children (54.9%), showed equivocal clinical symptoms and signs, requiring further management either overnight observation (11 cases) or ultrasonography (39 cases). Following observation, 7 patients (63.6%) were successfully treated without further imaging studies. On the contrary, after abdominal ultrasound (39 cases), appendices or other intra-abdominal pathologies could be demonstrated, leading to definitive diagnosis and treatment in 17 patients (43.6%), except one false-positive case (5.9%). Only 6 patients had computed tomography (CT) scintigraphy following equivocal ultrasound findings. Accordingly, the treatment guidelines achieved an overall 93.4% accuracy. Clinical complaints were statistically different as majority of cases with appendicitis having migratory pain (46.3%, P < 0.001). With logistic regression analysis, it was revealed that migratory pain, right lower quadrant (RLQ) tenderness, elevated white blood cell (WBC) count and high proportion of neutrophils were significantly associated with appendicitis.

Conclusion: Pediatric appendicitis is occasionally arduous to diagnose. By minimizing the utilization of CT scan, our treatment guidelines accomplish high accuracy. Careful history taking, thorough physical examination, and basic laboratories were crucial for accurate diagnosis.

Downloads

Download data is not yet available.

References

St Peter SD, Sharp SW, Holcomb GW, 3rd, Ostlie DJ. An evidence-based definition for perforated appendicitis derived from a prospective randomized trial. J Pediatr Surg 2008;43:2242-5.

https://doi.org/10.1016/j.jpedsurg.2008.08.051

Glass CC, Rangel SJ. Overview and diagnosis of acute appendicitis in children Semin Pediatr Surg 2016;25:198-203.

https://doi.org/10.1053/j.sempedsurg.2016.05.001

Rice-Townsend S, Barnes JN, Hall M, Baxter JL, Rangel SJ. Variation in practice and resource utilization associated with the diagnosis and management of appendicitis at freestanding children's hospitals: implications for value-based comparative analysis. Ann Surg 2014;259:1228-34.

https://doi.org/10.1097/SLA.0000000000000246

El-Gohary Y, Molina M, Chang J, Dodd A, Miller E, Harrell C, et al. The use of computed tomography versus clinical acumen in diagnosing appendicitis in children: A two-institution international study. J Pediatr Surg 2021;56:1356-61.

https://doi.org/10.1016/j.jpedsurg.2020.09.061

Brenner D, Elliston C, Hall E, Berdon W. Estimated risks of radiation-induced fatal cancer from pediatric CT. AJR Am J Roentgenol 2001;176:289-96.

https://doi.org/10.2214/ajr.176.2.1760289

Larson DB, Johnson LW, Schnell BM, Goske MJ, Salisbury SR, Forman HP. Rising use of CT in child visits to the emergency department in the United States, 1995-2008. Radiology 2011;259:793-801.

https://doi.org/10.1148/radiol.11101939

Miglioretti DL, Johnson E, Williams A, Greenlee RT, Weinmann S, Solberg LI, et al. The use of computed tomography in pediatrics and the associated radiation exposure and estimated cancer risk. JAMA Pediatr 2013:167:700-7.

https://doi.org/10.1001/jamapediatrics.2013.311

Shah NB, Platt SL. ALARA: is there a cause for alarm? Reducing radiation risks from computed tomography scanning in children. Curr Opin Pediatr 2008:20:243-7.

https://doi.org/10.1097/MOP.0b013e3282ffafd2

Pearce MS, Salotti JA, Little MP, McHugh K, Lee C, Kim KP, et al. Radiation exposure from CT scans in childhood and subsequent risk of leukaemia and brain tumours: a retrospective cohort study. Lancet 2012;380:499-505.

https://doi.org/10.1016/S0140-6736(12)60815-0

Meulepas JM, Ronckers CM, Smets A, Nievelstein RAJ, Gradowska P, Lee C, et al. Radiation exposure from pediatric CT scans and subsequent cancer risk in the Netherlands. J Natl Cancer Inst 2019;111:256-63.

https://doi.org/10.1093/jnci/djy104

Keating EM, Orth RC, Bisset GS, Starke HE, Cruz AT. Utility of computed tomography overreading and abdominal ultrasound in children with suspected appendicitis and nondiagnostic computed tomography at Community Hospitals. Pediatr Emerg Care 2006; 36:564-70.

https://doi.org/10.1097/PEC.0000000000002283

Doria AS, Moineddin R, Kellenberger CJ, Epelman M, Beyene J, Schuh S, et al. US or CT for diagnosis of appendicitis in children and adults? A meta-analysis. Radiology 2006;241:83-94.

https://doi.org/10.1148/radiol.2411050913

Schuh S, Man C, Cheng A, Murphy A, Mohanta A, Moineddin R, et al. Predictors of non-diagnostic ultrasound scanning in children with suspected appendicitis. J Pediatr 2011;158:112-8.

https://doi.org/10.1016/j.jpeds.2010.07.035

Tantisook T, Aravapalli S, Chotai PN, Majmudar A, Meredith M, Harrell C, et al. Determining the impact of body mass index on ultrasound accuracy for diagnosing appendicitis: Is it less useful in obese children? J Pediatr Surg 2021;56:2010-5.

https://doi.org/10.1016/j.jpedsurg.2021.01.023

Butler M, Servaes S, Srinivasan A, Edgar JC, Del Pozo G, Darge K. US depiction of the appendix: role of abdominal wall thickness and appendiceal location. Emerg Radiol 2011;18:525-31.

https://doi.org/10.1007/s10140-011-0977-0

Anderson KT, Bartz-Kurycki MA, Austin MT, Kawaguchi AL, Kao LS, Lally KP, et al. Hospital type predicts computed tomography use for pediatric appendicitis. J Pediatr Surg 2019;54:723-7.

https://doi.org/10.1016/j.jpedsurg.2018.05.018

Yu YR, Shah SR. Can the Diagnosis of Appendicitis be made without a computed tomography scan? Adv Surg 2017;51:11-28.

https://doi.org/10.1016/j.yasu.2017.03.002

Lodwick DL, Cooper JN, Lawrence AE, Kelleher KJ, Minneci PC, Deans KJ. Factors affecting emergency department computed tomography use in children. J Surg Res 2019;241:294-301.

https://doi.org/10.1016/j.jss.2019.04.014

Sullins VF, Rouch JD, Lee SL. Malpractice in cases of pediatric appendicitis. Clinical Pediatrics 2017;56:226-30.

https://doi.org/10.1177/0009922816656621

Rich BS, Shelton K, Glick RD. Litigation involving pediatric surgical conditions. J Pediatr Surg 2020;55:602-8.

https://doi.org/10.1016/j.jpedsurg.2019.08.047