Overview and diagnosis of acute appendicitis in children
Introduction
Abdominal pain is one of the most common chief complaints of children seen in the emergency department, and appendicitis represents the most common abdominal surgical emergency in the pediatric population. Appendicitis occurs in approximately 70,000 children in the United States per year and accounts for approximately one-third of childhood admissions for abdominal pain and nearly 30% of the cumulative cost of all pediatric general surgical conditions combined.1, 2, 3, 4 Despite being a relatively common condition, diagnosis of appendicitis in children can prove challenging in many cases. In a retrospective cohort study of 13,328 patients, Rice-Townsend et al.5 characterized wide variation in the diagnostic approach to suspected appendicitis among children׳s hospitals, including a 3.5-fold variation in preoperative imaging and a 5-fold variation in laboratory utilization. According to data from the American College of Surgeon׳s Pediatric National Quality Improvement Program, 65% of children who underwent appendectomy for suspected appendicitis received a preoperative ultrasound and 42% underwent a computed tomography (CT) scan.6 Several factors may underlie this practice variation, including differences among hospitals with available resources and in the perceived value of different diagnostic adjuncts used individually and in combination. The goals of this article are to review the available evidence surrounding the predictive value of presenting signs and symptoms, laboratory tests and imaging studies for diagnosing appendicitis. Furthermore, we sought to explore the predictive utility of composite measures based on multiple sources of diagnostic information, as well as the utility of clinical pathways as a means to streamline the diagnostic process.
Section snippets
Clinical presentation
The classic presentation of appendicitis has been well described, and includes fever, anorexia, nausea, guarding, and migration of pain from the umbilical region to the right lower quadrant.7 However, the predictive value of these signs and symptoms for appendicitis has been found to be relatively weak in many studies. In one of the largest such studies which included 755 children presenting to the emergency department (ED) with abdominal pain, Becker et al. found that many of these “classic”
References (56)
- et al.
Current management of appendicitis
Semin Pediatr Surg
(2007) - et al.
Predictive value of white blood cell count and C-reactive protein in children with appendicitis
J Pediatr Surg
(2007) - et al.
ACR Appropriateness Criteria® right lower quadrant pain—suspected appendicitis
J Am Coll Radiol
(2011) - et al.
Glowing in the dark: time of day as a determinant of radiographic imaging in the evaluation of abdominal pain in children
J Pediatr Surg
(2011) - et al.
Predictors of non-diagnostic ultrasound scanning in children with suspected appendicitis
J Pediatr
(2011) - et al.
Reducing computed tomography scans for appendicitis by introduction of a standardized and validated ultrasonography report template
J Pediatr Surg
(2015) - et al.
Advanced radiologic imaging for pediatric appendicitis, 2005–2009: trends and outcomes
J Pediatr
(2012) - et al.
The diagnosis of acute appendicitis in a pediatric population: to CT or not to CT
J Pediatr Surg
(2003) - et al.
An implemented MRI program to eliminate radiation from the evaluation of pediatric appendicitis
J Pediatr Surg
(2015) Pediatric appendicitis score
J Pediatr Surg
(2002)
A practical score for the early diagnosis of acute appendicitis
Ann Emerg Med
Using appendicitis scores in the pediatric ED
Am J Emerg Med
Prospective validation of the Pediatric Appendicitis Score
J Pediatr
Use of white blood cell count and polymorphonuclear leukocyte differential to improve the predictive value of ultrasound for suspected appendicitis in children
J Am Coll Surg
Integration of ultrasound findings and a clinical score in the diagnostic evaluation of pediatric appendicitis
J Pediatr
Does this child have appendicitis?
J Am Med Assoc
The epidemiology of appendicitis and appendectomy in the United States
Am J Epidemiol
Variation in practice and resource utilization associated with the diagnosis and management of appendicitis at freestanding children׳s hospitals: implications for value-based comparative analysis
Ann Surg
Diagnostic imaging practices for children with suspected appendicitis evaluated at definitive care hospitals and their associated referral centers
J Pediatr Surg
Atypical clinical features of pediatric appendicitis
Acad Emerg Med
Clinical practice. Suspected appendicitis
N Engl J Med
Normal leukocyte count and C-reactive protein value do not effectively exclude acute appendicitis in children
Dis Colon Rectum
The use of white blood cell count and left shift in the diagnosis of appendicitis in children
Pediatr Emerg Care
Appendicitis in paediatric age group: correlation between preoperative inflammatory markers and postoperative histological diagnosis
Afr J Paediatr Surg
Diagnostic accuracy of white cell count and C-reactive protein for assessing the severity of paediatric appendicitis
J R Soc Med Short Rep
Discriminative accuracy of novel and traditional biomarkers in children with suspected appendicitis adjusted for duration of abdominal pain
Acad Emerg Med
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