RESUMEN

BACKGROUND: Appendicitis is the most common reason children undergo acute general surgery but international, population-level disparities exist. This is hypothesised to be caused by preoperative delay and differential access to surgical care. The impact of prehospital factors on paediatric appendicitis severity in New Zealand is unknown. METHODS: A prospective, multicentre cohort study with nested parental questionnaire was conducted by a national trainee-led collaborative group. Across 14 participating hospitals, 264 patients aged ≤16 years admitted between January and June 2020 with suspected appendicitis were screened. The primary outcome was the effect of prehospital factors on the American Association for the Surgery of Trauma (AAST) anatomical severity grade. RESULTS: Overall, 182 children had confirmed appendicitis with a median age of 11.6. The rate of complicated appendicitis rate was 38.5% but was significantly higher in rural (44.1%) and Maori children (54.8%). Complicated appendicitis was associated with increased prehospital delay (47.8 h versus 20.1 h; P < 0.001), but not in-hospital delay (11.3 h versus 13.3 h; P = 0.96). Multivariate analysis revealed increased anatomical severity in rural (OR 4.33, 95% CI 1.78-7.25; P < 0.001), and Maori children (OR 2.39, 95% CI 1.24-5.75; P = 0.019), as well as in families relying on external travel sources or reporting unfamiliarity with appendicitis symptomology. CONCLUSION: Prehospital delay and differential access to prehospital determinants of health are associated with increased severity of paediatric appendicitis. This manifested as increased severity of appendicitis in rural and Maori children. Understanding the pre-hospital factors that influence the timing of presentation can better inform health-system improvements.

Asunto(s)

RESUMEN

BACKGROUND: Acute appendicitis is the most common surgical emergency in children. Eighty percent of paediatric appendicectomies are performed by adult general surgeons on an annual basis. The remaining 20% are performed at Children's Health Ireland (CHI) centres. Occasionally patients are transferred from Non-Specialist Paediatric Surgical Centres (NSPSC) for specialised pre-operative or post-operative care. AIM: To assess the rates of and characterise appendicitis-related referrals to CHI at Crumlin from NSPSC. METHODS: A retrospective review of all appendicitis-related transfers to CHI at Crumlin between January 2020 and December 2021 was performed. Data relating to indications for transfer, referring hospital level, patient demographics, management, type of surgery, length of stay (LOS), and radiological studies were collected and analysed. RESULTS: Seventy-two patients were transferred to CHI at Crumlin over the 2-year period. A total of 60.9% were male, mean age 9 ± 4.3 years, mean LOS 6.0 ± 2.2 days (range 1-30 days). Nineteen percent were under 5 years of age. Seventy-three percent were transferred from level 4 centres. Ninety-seven percent were transferred pre-operatively, 25% of those transferred pre-operatively had imaging in CHI confirming appendicitis. Fifty-five percent (40/72) of patients had pre-operative imaging performed. A total of 37.5% (15/40) confirmed complicated appendicitis. Twenty percent (8/40) underwent both ultrasound and computerised tomography (CT) at the referring centre. A total of 2.7% (2/72) were transferred with known co-morbidities. Ninety-two percent (66/72) underwent appendicectomy. Eight percent (6/72) were managed non-operatively (NOM) - 2 failed NOM, 2 underwent interval appendicectomy. Of those managed operatively, 76% (50/66) underwent laparoscopic appendicectomy, and 24% (16/66) were performed open. CONCLUSION: The majority of paediatric appendicectomies are performed at Non-Specialist Paediatric Surgical Centres. It is vital to maintain this working relationship so that specialist paediatric centres are available to provide care to complex paediatric patients.

Asunto(s)

RESUMEN

Introduction: In this study, we prospectively investigated changes in serum interleukin-6 (IL-6), high-sensitivity C-reactive protein (hsCRP) and full white blood cell (WBC) counts during the diagnosis and treatment of paediatric patients with appendicitis. We also investigated the effects of the COVID-19 pandemic on the diagnosis and treatment processes of paediatric appendicitis patients. Materials and Methods: A non-perforated appendicitis group (n = 110), a perforated appendicitis group (n = 35) and an appendicitis + COVID-19 group (n = 8) were formed. Blood samples were taken upon admission and every day until the three studied parameters returned to normal values. To investigate the effects of the COVID-19 pandemic on paediatric appendicitis patients, the perforated appendicitis rates and the times from the onset of the first symptoms to the operation before and during the pandemic were compared. Results: WBC, IL-6, and hsCRP dropped below the upper limits on the second postoperative day in the non-perforated appendicitis group, four to six days postoperatively in the perforated appendicitis group, and three to six days postoperatively in the appendicitis + COVID-19 group. These parameters were not within normal range in patients who developed complications during follow-up. The time from the onset of abdominal pain to the surgery was significantly longer during than before the pandemic in both the non-perforated appendicitis group and the perforated appendicitis group. Conclusions: Our results show that WBC, IL-6, and hsCRP are useful laboratory parameters that can complete clinical examinations in the diagnosis of appendicitis in paediatric patients and the identification of complications that may develop postoperatively.

Asunto(s)

RESUMEN

AIM: This study examined if the classification systems for acute appendicitis could be applied in the emergency department as an indicator for surgical consultation, in order to reduce unnecessary paediatric surgery admission. METHODS: The Alvarado Score (ALS) and the Pediatric Appendicitis Score (PAS) were applied. The decisions for hospitalisation and treatment were made independent of the scores. RESULTS: In total, 307 children with abdominal pain suggestive of acute appendicitis were included. We used a cut-off point of 7 and divided the patients into groups; the group with score ≥ 7 points was considered the positive ALS and/or PAS group, and the group with score < 7 points was the negative ALS and/or PAS group. The same process for cut-values set at 6 points was followed. The joint probabilities for the 7-point-thresholds were: ALS-sensitivity 84%, PAS-sensitivity 85%, ALS-specificity 92%, PAS-specificity 92%, ALS-positive predictive value (PPV) 83%, PAS-PPV 84% and 93% negative predictive value (NPV) for both scores. Considering the 6-point-thresholds, we estimated: 94% sensitivity for both scores, 74% ALS-specificity, 84% PAS-specificity, 66% ALS-PPV, 73% PAS-PPV, 91% ALS-NPV and 97% PAS-NPV. CONCLUSION: The scoring systems provided acceptable prediction of patients with and without appendicitis. They may be of use in the emergency department, as assistive diagnostic-tools, in order to reduce paediatric surgery consultations, admissions and treatment costs.

Asunto(s)

RESUMEN

Introduction: The diagnosis of acute appendicitis (AA) is usually clear cut but sometimes there is atypical presentation of this condition in children. There is a need to determine and compare the diagnostic accuracy of these three pre-operative diagnostic modalities: Paediatric Appendicitis Score (PAS), abdominal ultrasonographic scan (USS) findings, and serum C-reactive proteins (CRPs). The objective of this study was to determine the diagnostic accuracy of the three diagnostic modalities and to compare each diagnostic test result with the histopathological results of the appendix specimens. Materials and Methods: This was a prospective cross-sectional study that involved children aged 4-15 years with suspected AA who presented at the emergency paediatric unit of a tertiary health care hospital in North Central, Nigeria. The PAS, quantitative serum CRP, and abdominal USS were performed for all eligible patients. Results: A total of 43 patients were included in this study. Forty appendicectomy specimens (93%) were histologically confirmed to be AA and three appendicectomy specimens (7%) were normal appendix. The diagnostic accuracy values of PAS, abdominal USS, and CRP were 95.3%, 93.0%, and 90.7%, respectively. Conclusion: This study demonstrated that PAS, abdominal USS, and serum CRP provided useful diagnostic accuracy for AA in children.

RESUMEN

BACKGROUND: Antibiotic choice for complicated appendicitis should be based on both microbiological effectiveness as well as ease of administration and cost especially in lower resourced settings. Data is limited on comparative morbidity outcomes for antibiotics with similar microbiological spectrum of activity. Incidence and morbidity of surgical site infection after appendectomy for complicated appendicitis was assessed after protocol change from triple antibiotic (ampicillin, gentamycin, and metronidazole) regimen to single agent (amoxycillin/clavulanic acid). METHODS: Surgical site infection (SSI) rate, relook surgery rate and length of hospital stay were retrospectively compared in patients treated for acute appendicitis preceding (2014, 2015; "triple-therapy, TT") and following (2017, 2018; "single agent, SA") antibiotic protocol change. RESULTS: The rate of complicated appendicitis was similar between groups; 72.6% in TT and 66% in SA (p = 0.239). Significantly, SSI occurred in 22.7% of the SA group compared to 13.3% in TT group (OR 1.920, 95% CI 1.000-3.689, p = 0.048). Use of laparoscopy increased from 31% in TT to 89% in SA, but with subgroup analysis this was not associated with increased SSI (17.3% in open and 20.6% in laparoscopic; OR 0.841, 95% CI 0.409-1.728, p = 0.637). Relook rate (OR 1.444, 95% CI 0.595-3.507, p = 0.093) length of hospital stay (U = 6859, z = -1.163, p = 0.245), and ICU admission (U = 7683, z = 0.634 p = 0.522) were equivocal. Neither group had mortalities. CONCLUSIONS: Despite increased SSI with SA, overall morbidity relating to ICU admission, relook rate and length of hospital stay was similar in both groups. More prospective research is required to confirm equivalent overall morbidity and that single agent therapy is more cost-effective with acceptable clinical outcomes.

Asunto(s)

RESUMEN

OBJECTIVE: This study aimed to investigate the diagnostic value of presepsin, a new inflammatory marker for paediatric appendicitis, and to determine a reference range of presepsin for children. METHODS: This single-center prospective study was conducted in our paediatric emergency department between 1 February 2021 and 1 July 2021. Patients aged 0-18 years diagnosed with acute appendicitis, which was pathologically confirmed, and healthy volunteers in the same age group were included in the study. Serum presepsin levels were analysed using an enzyme-linked immunosorbent assay reader. In addition to presepsin, other acute-phase reactants, paediatric appendicitis scores and imaging methods were evaluated. RESULTS: There were 94 patients in the acute appendicitis group and 102 healthy volunteers in the control group. Median values were compared between the two groups, and no statistically significant differences were found (p = 0.544). In addition, no statistically signivficant differences in presepsin levels were found between the acute and perforated appendicitis groups (p = 0.344). The median (IQ1-IQ3) reference range for presepsin in healthy children was 0.9950 (0.7575-1.610) ng/mL. CONCLUSION: Presepsin is not a suitable marker for the diagnosis of acute appendicitis. We observed that serum presepsin levels were not elevated in paediatric appendicitis, which is a local infection, in contrast to previous studies.

Asunto(s)

RESUMEN

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.

RESUMEN

PURPOSE: As appendicitis in children can be managed differently according to the severity of the disease, we investigated whether commonly used serum biomarkers on admission could distinguish between simple and complicated appendicitis. METHODS: Admission white blood cell (WBC), neutrophil (NEU), and C-reactive protein (CRP) levels were analysed by ROC curve, and Kruskal-Wallis and contingency tests. Patients were divided according to age and histology [normal appendix (NA), simple appendicitis (SA), complicated appendicitis (CA)]. RESULTS: Of 1197 children (NA = 186, SA = 685, CA = 326), 7% were <5 years, 55% 5-12, 38% 13-17. CA patients had higher CRP and WBC levels than NA and SA (p < 0.0001). NEU levels were lower in NA compared to SA or CA (p < 0.0001), but were similar between SA and CA (p = 0.6). CA patients had higher CRP and WBC levels than SA patients in 5-12- (p < 0.0001) and 13-17-year groups (p = 0.0075, p = 0.005), but not in <5-year group (p = 0.72, p = 0.81). We found CRP >40 mg/L in 58% CA and 37% SA (p < 0.0001), and WBC >15 × 109/L in 58% CA and 43% SA (p < 0.0001). CONCLUSIONS: Admission CRP and WBC levels may help the clinician predict complicated appendicitis in children older than 5 years of age. Early distinction of appendicitis severity using these tests may guide caregivers in the preoperative decision-making process.

Asunto(s)

RESUMEN

INTRODUCTION: Intestinal malrotation is a congenital rotational anomaly that occurs as a result of an arrest of normal rotation of the embryonic gut, said to occur in 1 in 6000 live births. Due to the abnormal caecal and appendix position, diagnosis of acute appendicitis becomes more challenging, thus leading to diagnostic and operative intervention delays. Our aim is to highlight the diagnostic challenges in this clinical scenario. PRESENTATION OF CASE: We present a case of a 10 year old boy with previously undiagnosed intestinal malrotation with a left sided acute appendicitis. Initial symptoms lead to a treatment for gastroenteritis, however, due to ongoing pain a CT abdomen was done which showed the malrotation and appendicitis. He required a laparoscopy converted to open appendicectomy due to an appendicecal mass. DISCUSSION: Historically, intestinal malrotation was thought to be a disease of infancy with infrequent occurrence after the age of one year. However, recent analysis has shown an increase in presentations after one year of life into adulthood. Thus, the prevalence of malrotation in children and adults over the age of one year appear to be higher than initially presumed. CONCLUSION: Left sided acute appendicitis is a diagnostic dilemma, thus often leading to management delays. It is pertinent to remember that malrotation of the gut is more common than previously thought, and not just a disease of infancy. It is advisable to consider imaging studies while balancing the risk-benefit-ratio of radiation exposure, especially in paediatric cases to cinch the diagnosis.

RESUMEN

OBJECTIVES: To describe current practice in managing children with possible acute appendicitis in EDs in Australia and New Zealand as the basis for a clinical practice guideline (CPG). METHODS: An anonymous survey was distributed to consultant emergency physicians working at PREDICT (Paediatric Research in Emergency Departments International Collaborative) sites in Australia and New Zealand in April 2013. A second, site-based survey was distributed to the PREDICT representatives at each of the 13 sites. RESULTS: The response rate was 100% (13/13) for the site-based survey and 82% (145/176) for the physician survey. Most respondents agreed that right lower quadrant (RLQ) tenderness (94%), anorexia (92%), migration of abdominal pain to the RLQ (86%), rebound tenderness in the RLQ (60%) and RLQ tenderness produced on coughing, hopping or percussion (63%) were valuable symptoms and signs in diagnosing appendicitis. The responses regarding nausea and vomiting and fever were less consistent. Less than 50% regarded blood tests (C-reactive protein, white cell count) as relevant for the diagnosis of appendicitis. Most physicians (61%) agreed there was a role for a validated CPG for possible appendicitis in children, although only 3/13 sites reported use of such a CPG. CONCLUSIONS: This survey of senior emergency physicians across Australia and New Zealand demonstrated congruence in several clinical markers and disagreements in others in the approach to diagnosing children with possible appendicitis. Whereas emergency physicians would like a validated CPG, this survey has highlighted some critical issues. Particularly, the low regard for blood tests, integral to published diagnostic scoring systems, will be a challenge for the development and introduction of such a CPG in Australia and New Zealand.

Asunto(s)