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Predictors for Acute Appendicitis in Children
Laurie Malia1, Jesse J Sturm1, Sharon R Smith1
1From the Department of Emergency Medicine, Connecticut Children's Medical Center.
Insights
Ultrasound (US) findings like increased appendix diameter, appendicolith, or inflammatory changes help diagnose appendicitis in children. Absence of these signs, along with a normal white blood cell (WBC) count and small appendix diameter, can rule out appendicitis when the appendix is visualized.
Area of Science:
- Pediatric Emergency Medicine
- Diagnostic Imaging
- Surgical Pathology
Background:
- Acute appendicitis is a common pediatric emergency.
- Discrepancies in diagnosing appendicitis can occur even when the appendix is visualized on ultrasound (US).
- Secondary US findings aid in evaluating children with suspected appendicitis.
Purpose of the Study:
- To identify specific ultrasound findings and laboratory results predictive of appendicitis in children with a visualized appendix.
- To improve diagnostic accuracy for pediatric appendicitis.
Main Methods:
- Prospective study of children (0-18 years) with suspected appendicitis.
- Analysis of ultrasound findings including appendix diameter, compressibility, vascularity, appendicolith, inflammatory changes, periappendiceal fluid, and tenderness.
- Diagnosis confirmed by surgical pathology.
Main Results:
- Of 1252 patients, 762 had visualized appendices; 35.2% were diagnosed with appendicitis.
- Appendix diameter ≥7 mm (OR 12.4), appendicolith (OR 3.9), inflammatory changes (OR 10.2), and WBC count ≥10,000/μL (OR 4.8) significantly increased appendicitis likelihood.
- Abdominal pain duration ≥3 days decreased likelihood (OR 0.3).
- Absence of inflammatory changes, WBC <10,000/μL, and appendix diameter ≤7 mm had 100% negative predictive value.
Conclusions:
- In cases of suspected appendicitis with a visualized appendix, specific US findings and lab results are crucial.
- The absence of inflammatory changes, a WBC count <10,000/μL, and an appendix diameter ≤7 mm strongly suggest against appendicitis.
- These negative findings can help decrease suspicion and potentially avoid unnecessary interventions.
Background:
Acute appendicitis in children is the most common condition requiring urgent evaluation and surgery in the emergency department. At times, despite the appendix being seen on ultrasound (US), there can be discrepancy as to whether a patient has clinical appendicitis. Secondary findings suggestive of appendicitis can be helpful in identifying and evaluating these children.
Objective:
The aim of this study was to determine if specific US findings and/or laboratory results are predictive of appendicitis in children with a visualized appendix on US.
Methods:
A prospective study was conducted on children (birth to 18 years) presenting to the pediatric emergency department with suspected appendicitis who underwent right-lower-quadrant US. Ultrasound findings analyzed appendix diameter, compressibility, increased vascularity, presence of appendicolith, inflammatory changes, right-lower-quadrant fluid near the appendix, lower abdominal fluid, tenderness during US, and lymph nodes. Diagnosis was confirmed via surgical pathology.
Results:
There were 1252 patients who enrolled, 60.8 (762) had their appendix visualized, and 39.1 (490) did not. In children where the appendix was seen, 35.2% (268) were diagnosed with appendicitis. Among patients with a visualized appendix, the likelihood of appendicitis was significantly greater if the appendix diameter was 7 mm or greater (odds ratio [OR], 12.4; 95% confidence interval [CI], 4.7-32.7), an appendicolith was present (OR, 3.9; 95% CI, 1.5-10.3), inflammatory changes were seen (OR, 10.2; 95% CI, 3.9-26.1), or the white blood cell (WBC) count was 10,000/μL (OR, 4.8; 95% CI, 2.4-9.7). A duration of abdominal pain of 3 days or more was significantly less likely to be associated with appendicitis (OR, 0.3; 95% CI, 0.08-0.99). The absence of inflammatory changes, WBC count of less than 10,000/μL, and appendix diameter of 7 mm or less had a negative predictive value of 100%.
Conclusions:
When the appendix is seen on US but diagnosis of appendicitis is questioned, the absence of inflammatory changes, WBC count of less than 10,000/μL, and appendix diameter of 7 mm or less should decrease suspicion for appendicitis.
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