Advancements in the Diagnosis of Acute Appendicitis in Children and Adolescents

Abstract

The aim of our study was to further improve the preoperative diagnosis of acute appendicitis in children and adolescents. All diagnostic parameters from the patients' medical history (duration and quality of abdominal pain, stool behaviour), the laboratory (leukocytes, C-reactive protein), the clinic (defense, tenderness on percussion, nausea, vomiting, dry tongue) and repeated ultrasound investigations (visualisation of the appendix, indirect signs of an inflammatory process in the appendix region) were documented prospectively and were re-assessed with regard to their diagnostic value. As an additional parameter, procalcitonin was determined. 1156 patients (593 male/563 female) with a mean age of 9.51 years (+/- 1.2 yrs) (max. 15 yrs/min. 2.3 yrs), referred to the department with acute abdominal pain, were examined. 233 (141 male/92 female; 20.1 %) of these patients with a mean age of 10.47 years (+/- 1.1 yr) had appendicitis. Based on the patients' medical history, laboratory findings, the initial clinical investigation and the initial ultrasound investigation, 173 patients (74.3 % of the later operated 233 children with appendicitis) were diagnosed with certainty. The diagnosis of 60 patients (25.7 %) of this group remained uncertain. These patients received a saline enema (Clysmol, Pharmacia & Upjohn Company) and were subjected to a second clinical and sonographic investigation after approximately four hours of parenteral fluid substitution (Ringer's lactate, Mayrhofer Pharmazeutika Company, 4 ml/kg/h). The other 923 patients (79.83 %) were discharged and were followed up as outpatients in the following days. Based on this stepwise procedure, the percentage of correctly diagnosed appendicitis could be increased to 97.4 %. The measurement of procalcitonin proved to be of no value in the diagnosis of acute appendicitis. It may be concluded that in children with abdominal pain, high diagnostic accuracy can only be achieved by a carefully combined evaluation of all individual diagnostic parameters and repeated investigations.

Acute Appendicitis In Young Children-A Diagnostic Challenge

“…Atypical clinical findings are seen in 30-50% of children, especially the younger ones and often leads to a delayed diagnosis. 2,3 It is however a rare disease in infants and very young children. 4 The diagnosis is usually based on medical history and physical examination.…”

“…Human Immunodeficiency Virus 1 and II screen, Widal test, Random blood sugar, and Electrolytes, urea and creatinine were normal. Total white blood cell count was 7,700 cells/ mm 3 , neutrophils 60%, lymphocytes 35%, monocytes 0% eosinophils 5% and basophils 0%.…”

“…3,12,13 Several scoring systems have been designed to improve the accuracy of preoperative diagnosis 12,14,15 but none has proved satisfactory.…”

“…17 Similarly measurement of procalcitonin levels proved to be of no value in the diagnosis of acute appendicitis. 18 The investigation of the acute abdomen in infants and children has evolved during the last two decades, placing radiologists at the forefront of the evaluation and diagnosis of acute right lower quadrant abdominal problems. 19 Ultrasound and Computerised Tomography (CT) scans of the abdomen have increasingly become helpful in reaching a diagnosis, although some worry on the widespread use of CT in children has been expressed concerning radiation.…”

“…20 An improvement in the diagnoses has been reported in a second clinicial and sonographic examination after fluid substitution and the application of large bowel enema. 3,18 Routine ultrasound study in paediatric patients with suspected acute appendicitis is a worthwhile diagnostic procedure that may save money, shorten hospital stay, decrease the complication rate and avert unnecessary surgery. 21 CT is a complementary tool 2 but in the developing nations like Nigeria these imaging tools may not be accessible or affordable by the patient.…”