An easy-to-follow algorithm to improve pre-operative diagnosis for appendicitis in children

Abstract

Summary Goal:To evaluate physician compliance with use of a diagnostic algorithm for appendicitis in children. Our secondary objective was to determine the impact of the algorithm on diagnostic accuracy and morbidity. Methods: We conducted a clustered randomized trial in eight centers. A total of 866 patients were included and, depending on the period of randomization at particular centers, 543 patients were managed before the formal institution of the diagnostic algorithm; their diagnostic management was compared to that of the subsequent 323 patients. Results: There was a 29.1% mean increase in the use of imaging studies included in the algorithm after algorithm set-up, rising from 50.8 to 79.9% (P < 0.02). When we used a composite endpoint of ''poor results'' (grouping patients with incorrect diagnoses and/or post-operative complications), no statistically significant difference was found between the two periods (85/543 (15.6%) before vs. 45/323 (13.9%) after set-up, P = 0.5). But when the number of incorrect diagnoses of appendicitis made without the use of the algorithm was compared to that of patients who took advantage of the algorithm, the difference was highly significant (67/332 [20.2%] vs. 63/534 [11.8%], P < 0.001), and the rate of unnecessary appendectomy decreased from 11.9 to 5.3% (P < 0.01). Conclusions: Our diagnostic algorithm improved the adherence to good practice for the diagnosis of appendicitis in children, reducing the rates of unnecessary appendectomy and morbidity. This strategy, combining laboratory tests and imaging, should permit pediatric surgeons to adapt their therapeutic approaches to specific cases.

Paediatric appendiceal ultrasound: a survey of Australasian sonographers’ opinions on examination performance and sonographic criteria

“…However, diagnosis in children can be complex, with clinical assessment often limited by challenges in communication and history that are more easily addressed in an adult cohort. Whilst typical clinical findings as well as blood counts and inflammatory markers can suggest appendicitis, imaging is often required when the diagnosis is uncertain . The utility of ultrasound examination in diagnosing appendicitis has been reviewed and analysed, with the critical role of the sonographer acknowledged in diagnostic accuracy …”

Diagnosis and management of acute appendicitis in 21 pediatric hematology and oncology patients at a tertiary care cancer center

“…Although not possible in all cases, our policy was to operate as soon as possible in order to avoid a "locus minoris resistantiae", which may cause www.nature.com/scientificreports/ a recurrent episode of appendicitis and/or typhlitis during the next phase of neutropenia as observed in 2 of our 21 patients. While the management of typhlitis comprises the early use of broad-spectrum antibiotics and bowel rest, appendectomy might be the treatment of choice for "pure" appendicitis 2,3,10,15,16 . Whether laparoscopic appendectomy is the preferred procedure in neutropenic children is discussed controversially.…”

“…Appendicitis is an inflammation of the appendix, which leads to an increased diameter of the organ to ≥ 0.6 cm and corresponding clinical signs. Given the rarity of acute appendicitis in the setting of immunosuppression, reliable data on the frequency, presentation, and outcome are scarce, with most data coming from case reports or small series 1 , 7 – 10 . Accordingly, risk factors and optimal management of acute appendicitis in hemato-oncologic patients have not yet been definitely established.…”

Comparison of Alvarado score and pediatric appendicitis score for clinical diagnosis of acute appendicitis in children—a prospective study

“…In these circumstances, explorations reveal negative appendectomies and an organ with potential functions can be lost [5]. While for neglected cases there is an unnecessary delay for making a diagnosis of acute appendicitis which can lead to gross complications including perforation [6], these complications can increase morbidity, mortality, and hospital stay which are an economic and social burden to the community. Moreover, differential diagnosis of an acutely inflamed appendix in children includes a vast variety of diseases.…”