Management of pediatric acute appendicitis in the computed tomographic era
Kuojen Tsao1, Shawn D St Peter, Patricia A Valusek
1Department of Surgery, The Children's Mercy Hospital, Kansas City, Missouri, USA. Kuojen.Tsao@uth.tmc.edu
Insights
Computed tomography (CT) scans improve the preoperative diagnosis of appendicitis in children, offering a higher positive-predictive value than physical exams alone. This enhanced accuracy aids in guiding treatment for complicated appendicitis.
Area of Science:
- Pediatric surgery
- Diagnostic imaging
- Gastrointestinal disease
Background:
- Management of complicated appendicitis in children is evolving.
- Accurate preoperative diagnosis is crucial for optimal treatment.
- Computed tomography (CT) plays a role in preoperative assessment.
Purpose of the Study:
- To evaluate the accuracy of preoperative diagnosis, including CT scans.
- To assess the influence of CT on managing perforated and nonperforated appendicitis in children.
Main Methods:
- A 6-year retrospective review of pediatric appendectomy patients.
- Analysis of preoperative diagnosis accuracy using CT scans versus clinical evaluation.
- Categorization of treatments including immediate surgery and initial nonoperative management.
Main Results:
- CT scans were used in 64.7% of appendectomies, with a 96.4% positive-predictive value for appendicitis.
- CT scans indicated perforation in 28.1% of positive cases.
- History and physical alone had a 90.8% positive-predictive value for appendicitis.
Conclusions:
- CT scans provide a statistically more accurate preoperative diagnosis of appendicitis than clinical evaluation alone.
- CT evaluation can guide therapy towards initial nonoperative management for complicated appendicitis.
- Further research is needed to confirm the efficacy of nonoperative management regimens.
Background/Purpose:
The treatment options for complicated appendicitis in children continue to evolve. Optimal management of complicated appendicitis relies on an accurate preoperative diagnosis. We examined the accuracy of our preoperative diagnosis including computed tomography (CT) and the influence on the management of children with perforated and nonperforated appendicitis.
Methods:
Following IRB approval, a 6-year review of all patients that underwent an appendectomy for suspected appendicitis was performed. Treatments included immediate operations and initial nonoperative management (antibiotic therapy +/- percutaneous drainage of abscess). Appendicitis was confirmed by histological examination.
Results:
One thousand seventy-eight patients underwent appendectomy for suspected appendicitis. Preoperative CT scans were performed in 697 (64.7%) patients: 615 (88.2%) positive for appendicitis; 42 (6.0%) negative; and 40 (5.7%) equivocal. One hundred seventy-three (28.1%) positive CT scans further suggested perforation. Initial nonoperative management was initiated in 39 (22.5%) cases of suspected perforated appendicitis with abscess. The positive-predictive value (PPV) for suspected acute appendicitis based on history and physical examination alone was 90.8%. The PPV for positive CT scan for acute appendicitis was 96.4% with a PPV of 91.9% for positive CT scan for perforated appendicitis.
Conclusions:
The correct preoperative diagnosis of appendicitis appears statistically more accurate with CT scan compared to history and physical examination alone (PPV 96.4% versus 90.8%, P = 0.045). For those with clinically suspicious complicated appendicitis, CT evaluation may direct therapy toward initial nonoperative management. The efficacy of this regimen warrants further investigation.
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