Acute Appendicitis in Children Younger than Five Years of Age: Diagnostic Challenge for Pediatric Surgeons

Pogorelić, Zenon; Domjanović, Josipa; Jukić, Miro; Peričić, Tina Poklepović

doi:10.1089/sur.2019.175

Cited by 60 publications

(59 citation statements)

References 18 publications

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“…Indeed, an initial diagnostic error rate ranging from 28 to 57% is reported in children 12 years old or younger and can reach 100% in those 2 years of age or younger [2]. A recent study showed a significant increase of perforation in relation with age as follows: 100% < 1 year; 100% 1-2 years; 83,3% 2-3 years; 71,4% 3-4 years; 78,6% 4-5 years and 47,3% 5 years [3].…”

Section: Introductionmentioning

confidence: 98%

Influence of age on clinical presentation, diagnosis delay and outcome in pre-school children with acute appendicitis

Lounis¹,

Hugo²,

Demarche

et al. 2020

BMC Pediatr

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Background: Unusual clinical presentation of acute appendicitis in preschool children leads to misdiagnosis and complications. We aimed to analyze the influence of age on clinical presentation, laboratory findings and complications in preschool children with acute appendicitis. Methods: From January 2012 until December 2017, 29 children younger than 6 years of age (median 50 months) with acute appendicitis were enrolled in this retrospective study. Patients were grouped according to their age: group 1: < 48 months (n = 13); group 2: > 48 months (n = 16), their clinical data, laboratory results and complications were compared. Results: In group 1, duration of nausea and vomiting was longer, alteration of general state was more frequent and pain in the right fossa iliaca less frequent than in group 2 (p = 0.026, p = 0.000 and p = 0.029, respectively). Heart rate was higher in group 1 than in group 2 (p = 0.012). Leucocyte and polynuclear neutrophil counts were lower in group 1 than in group 2 (p = 0.028 and = 0.004, respectively) but C-reactive protein levels were not different between groups. In the whole cohort however, C-reactive protein at admission value correlated negatively with age (p = 0.025). Abdominal ultrasound allowed diagnosis in 19/29 patients (65.5%), without any difference between groups. Appendicular perforation was more frequent in group 1 than in group 2 (p = 0.003). Perforation was also related to longer hospital stay (p = 0.018). Peritonitis occurred in 21/29 (72%), post-operative ileus in 5/29 (17%) and sepsis in 4/29 (14%) patients without any difference between groups. In the whole cohort, hospital stay correlated negatively with age (p = 0.000). There was no mortality. Conclusions: Among preschool children, those younger than 48 months present with longer duration of preadmission symptoms indicating longer infection course than in older children. Altered general state and higher degree of tachycardia in the younger reflect higher systemic repercussions of the illness. Less specific abdominal pain and dissociation of the inflammatory markers with lower leucocyte-and neutrophil counts and higher Creactive protein levels in the younger may contribute to further diagnosis delay and higher rate of perforation in these patients.

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Section: Introductionmentioning

confidence: 98%

Influence of age on clinical presentation, diagnosis delay and outcome in pre-school children with acute appendicitis

Lounis¹,

Hugo²,

Demarche

et al. 2020

BMC Pediatr

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show abstract

“…Perforation in this age group often leads to diffuse peritonitis, and the most important thing in the management is to establish the accurate diagnosis and perform surgical treatment, assisted by broadspectrum antimicrobial therapy [2,21,28] . Recently, several trials have focused on the non-operative treatment for AA [10,[29][30][31] .…”

Section: Aa Remains a Clinical Diagnosis With Laboratory And Radiologmentioning

confidence: 99%

“…The diagnosis of acute appendicitis has classic clinical appearance only in one third of all patients. Clinical appearance in the in the patients younger than ve years of age is often atypical, and misdiagnosis in this age group is not rare, which can lead to an increased rate of perforation [2] .…”

Section: Introductionmentioning

confidence: 99%

A clinical prediction model for complicated appendicitis in children younger than five years of age

Feng

Xing

et al. 2020

Preprint

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Background: No reliably specific method for complicated appendicitis has been identified in children younger than five years of age. This study aimed to analyze the independent factors for complicated appendicitis in children younger than five years of age, develop and validate a prediction model for the differentiation of simple and complicated appendicitis. Methods: A retrospective study of 382 children younger than five years of age with acute appendicitis from January 2007 to December 2016 was conducted with assessments of demographic data, clinical symptoms and signs, and pre-operative laboratory results. According to intraoperative findings and postoperative pathological results, acute appendicitis were divided into simple and complicated appendicitis. Univariate and multivariate analyses were used to screen out the independent factors of complicated appendicitis, and develop a prediction model for complicated appendicitis. Then 156 such patients from January 2017 to December 2019 were collected as validation sample to validate the prediction model. Test performance of the prediction model was compared with the ALVARADO score and Pediatric Appendicitis Score (PAS). Results: Of the 382 patients, 244 (63.9 %) had complicated appendicitis. Age, white blood cell count, and duration of symptoms were the independent factors for complicated appendicitis in children younger than five years of age. The final predication model for complicated appendicitis included factors above. In validation sample, the prediction model exhibited a high degree of discrimination (area under the curve [AUC]: 0.830; 95% confidence interval [CI]: 0.762 - 0.885) corresponding to a optimal cutoff value of 0.62, and outperformed the PAS (AUC: 0.735; 95% CI: 0.658 - 0.802), ALVARADO score (AUC: 0.733; 95% CI: 0.657 - 0.801). Conclusion : Age, white blood cell count, and duration of symptoms could be used to predict complicated appendicitis in children younger than five years of age with acute appendicitis. The prediction model is a novel but promising method that aids in the differentiation of acute simple and complicated appendicitis.

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“…The diagnosis of acute appendicitis has classic clinical appearance only in one third of all patients. Clinical appearance in the younger children is often atypical, and misdiagnosis in 3 this age group is not rare, which can lead to an increased rate of perforation [2] . Clinical presentation, Pediatric Appendicitis Score (PAS), ALVARADO score, Computed tomography, ultrasound and blood tests, may be helpful in diagnose of AA, but it is difficult to confirm the type of appendicitis (simple or complicated appendicitis) [3][4][5] .…”

Section: Introductionmentioning

confidence: 99%

C -reactive protein and albumin ratio for the diagnosis of complicated appendicitis in children

Feng

Yang

Xing

et al. 2020

Preprint

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Background: No reliably specific marker for complicated appendicitis has been identified. Serum C-reactive protein (CRP) and albumin (ALB) ratio (CRP/ALB ratio) has been a new inflammation-based prognostic score which is associated with the severity of inflammation. However, its value in the diagnosis of complicated appendicitis has not been studied. The aim of this study was to evaluate the predictive value of CRP/ALB ratio for complicated appendicitis in children. Methods: A retrospective study of 232 children with acute appendicitis was conducted with assessment of age, gender, symptom duration, albumin and blood routine indexes on admission. According to intraoperative findings and postoperative pathological results, patients were divided into the simple appendicitis group (127 cases) and complicated appendicitis group (105 cases). SPSS version 17 was used to analyse the data. Results: Of the 232 patients, 118 (50.9%) were male and 114 (49.1%) were female. The CRP/ALB ratio was higher in complicated appendicitis compared with simple appendicitis (p<0.05). Logistic regression analysis showed that the higher levels of mononuclear cell count (MC), CRP, procalcitonin (PCT) and CRP/ALB ratio were independent risk factors for complicated appendicitis in children. Receiver operating characteristic curve analysis showed that the area under the curve of CRP/ALB ratio (0.946) was was bigger than MC (0.619), CRP (0.906) and PCT (0.843). CRP/ALB ratio >1.43 was found to be a significant marker in predicting complicatedappendicitis with 91.4% sensitivity and 90.6% specificity. Compared with CRP/ALB ratio =<1.43, patients with CRP/ALB ratio >1.43 had a 102.22 times higher chance of complicated appendicitis (95% CI: 41.322 - 252.874). Conclusion: Admission CRP/ALB ratio was significantly higher in children with acute complicated appendicitis. It is a novel but promising hematological marker that aids the differentiation of acute complicated and simple appendicitis.

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Acute Appendicitis in Children Younger than Five Years of Age: Diagnostic Challenge for Pediatric Surgeons

Cited by 60 publications

References 18 publications

Influence of age on clinical presentation, diagnosis delay and outcome in pre-school children with acute appendicitis

Influence of age on clinical presentation, diagnosis delay and outcome in pre-school children with acute appendicitis

A clinical prediction model for complicated appendicitis in children younger than five years of age

C -reactive protein and albumin ratio for the diagnosis of complicated appendicitis in children

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