Perforation risk in pediatric appendicitis: assessment and management

Abstract

Perforated appendicitis, as defined by a visible hole in the appendix or an appendicolith free within the abdomen, carries significant morbidity in the pediatric population. Accurate diagnosis is challenging as there is no single symptom or sign that accurately predicts perforated appendicitis. Younger patients and those with increased duration of symptoms are at higher risk of perforated appendicitis. Elevated leukocytosis, bandemia, high C-reactive protein, hyponatremia, ultrasound, and CT are all useful tools in diagnosis. Distinguishing patients with perforation from those without is important given the influence of a perforation diagnosis on the management of the patient. Treatment for perforated appendicitis remains controversial as several options exist, each with its indications and merits, illustrating the complexity of this disease process. Patients may be managed non-operatively with antibiotics, with or without interval appendectomy. Patients may also undergo appendectomy early in the course of their index hospitalization. Factors known to predict failure of non-operative management include appendicolith, leukocytosis greater than 15,000 white blood cells per microliter, increased bands, and CT evidence of disease beyond the right lower quadrant. In this review, the indications and benefits of each treatment strategy will be discussed and an algorithm to guide treatment decisions will be proposed.

Experiencia en la atención de pacientes menores de 16 años con apendicitis aguda en el Hospital Universitario San Ignacio entre los años 2014 y 2019

“…Few peritoneal fluid cultures were performed, and this was one of the limitations of our study, since bacterial isolation is not routinely performed in acute appendicitis. This is in accordance with the recommendations of the American Society for Infectious Diseases, which indicate culture for epidemiological purposes only, to determine local microbiological patterns and optimize antibiotic treatment (14,16). The cultures performed were for aerobic germs, which is also presented in other studies published to date, since anaerobic germ cultures are more difficult and expensive (4,16).…”

“…Other published series report complicated appendicitis in 21.5% of patients (13). The rate of appendicular perforation varies between 5 and 62% in the literature, according to the population studied (13,14). The present study showed a perforation rate of 44.3%.…”

Predictive value of serum sodium level in determining complicated appendicitis risk in children

“…Early and accurate detection of perforated appendicitis in patients with acute appendicitis in the emergency room is important for determining the appropriate antibiotic therapy and timing of surgery. However, the diagnostic process is rather challenging in children since there is no definitive symptom or finding for clinical prediction of perforated appendicitis, pediatric patients might present with atypical signs and symptoms, and young children are usually unable to express their complaints clearly [12] . In the present study, the predictive value of basal serum Na level and inflammatory markers (leukocyte and neutrophil counts and serum CRP level) in the identification of cases with complicated appendicitis during emergency service monitoring was determined.…”

“…There are studies reporting different results and cut-off values on the diagnostic value of inflammatory markers, such as blood leukocyte and neutrophil counts and serum CRP levels in differentiating perforated appendicitis from simple appendicitis in children [3,4,[11][12][13][14] . Williams et al [3] reported that a leukocyte count >19.400/mm 3 in patients with acute appendicitis is an independent marker for perforated appendicitis, whereas Pham et al [11] reported this number to be >12.000/mm 3 .…”

“…There are several studies on the diagnostic value of laboratory tests performed to differentiate perforated appendicitis from simple appendicitis. Leukocyte count, neutrophil count, serum C-reactive protein (CRP) level, and sedimentation rate are among the most investigated parameters in these studies [3,4,[11][12][13][14] . In the literature, data on the relationship between perforated appendicitis and hyponatremia are very limited in pediatric patients.…”