Ceftriaxone-induced pseudolithiasis in children treated for perforated appendicitis

Purpose

Ceftriaxone has been associated with development of pseudolithiasis. In our institution, it is used for treatment of perforated appendicitis in children. This study evaluated the occurrence of ceftriaxone-related pseudolithiasis in this population.

Methods

After obtaining IRB approval, we performed a retrospective chart review over 51 months. We included patients undergoing laparoscopic appendectomy for perforated appendicitis. All patients were treated with ceftriaxone post-operatively. Patients without initial or post-treatment gallbladder imaging available for review were excluded.

Results

There were 71 patients who met inclusion criteria with a mean (±SD) age of 10.8 ± 3.8 years. Of these, 14 % (n = 10) developed stones or sludge in the gallbladder. The mean duration of ceftriaxone therapy was 8.7 ± 3.8 days. The average time to post-antibiotic imaging was 11.5 ± 10.3 days from initiation of antibiotics. There was no significant difference in duration of ceftriaxone therapy in the children that developed pseudolithiasis or sludge (10.0 ± 4.9 days) compared to those that did not (8.5 ± 3.6, p = 0.26). One child (10 %) with pseudolithiasis went on to become symptomatic, requiring a laparoscopic cholecystectomy.

Conclusions

In our experience, ceftriaxone use for perforated appendicitis is associated with a significant incidence of biliary pseudolithiasis, and is unrelated to duration of ceftriaxone therapy.     

Increased incidence of perforated appendicitis in children with obesity

Based on their clinical impression, the authors hypothesized that children with obesity may more commonly present with perforated appendicitis. Therefore, the authors reviewed their experience from 2008 to 2010 to determine whether obesity affected the clinical presentation of appendicitis. Variables studied were height, weight, use of diagnostic imaging, and clinical findings of appendicitis at presentation. Outcomes assessed were length of stay and complication rate. The study identified 319 patients with appendicitis. Children with obesity were more likely (P = .026) to present with perforation (28/62, 45%) than nonobese patients (78/257, 30%). Neither length of stay nor complication rate was affected by the presence of obesity. The data suggest that children with obesity are more likely to present with perforated appendicitis. This finding suggests that the diagnosis of appendicitis may be more difficult in obese patients or their presentation may be delayed. Practitioners should have heightened awareness in children with obesity and symptoms of abdominal pain.     

Harmonic US imaging of appendicitis in children

Background Harmonic imaging (HI), a relatively new ultrasound modality, was initially reported to be of use only in obese adult patients. HI increases the contrast and spatial resolution resulting in artefact-free images, and has been shown in adults to significantly improve abdominal sonography. Regarding its application in paediatric patients, just a handful reports exist and these do not encompass its use in intestinal sonography. Objective To compare the sonomorphological image quality of HI and fundamental imaging (FI, conventional grey-scale imaging) in the diagnosis of histologically confirmed appendicitis in children. Materials and methods For this prospective comparative study, 50 children (male/female 25/25; mean age 9.9 years) suspected of having appendicitis were recruited. In all patients US examination of the appendix and periappendiceal region was performed preoperatively and appendectomy carried out. The final diagnosis was based on histological examination of the appendix. Both FI and HI were used in the US examination (tissue harmonic imaging, THI; Sonoline Elegra, Siemens; 7.5 MHz linear transducer). A detailed comparison of the images from FI and HI was performed using a scoring system. The parameters compared included delineation of the appendiceal contour, wall, mucosa, contents of the appendix and surrounding tissues. Furthermore, periappendiceal findings such as mesenteric echogenicity, free fluid, lymph nodes and adjacent bowel wall thickening were compared. Results In 43 children (86%) acute appendicitis was histologically confirmed. The inflamed appendix could be depicted in the HI and FI modes in 93% and 86%, respectively. HI was found to be significantly better for the depiction of the outer contour, wall, mucosa and contents of the appendix (P<0.01). This was also true for the demonstration of free fluid, mesenteric lymph nodes, adjacent bowel walls and mesenteric echogenicity. Conclusion HI should be the preferred modality for scanning the right lower abdomen in suspected acute appendicitis. The diagnosis of acute appendicitis can then be more definitely ascertained.     

Diagnostic value of C-reactive protein in children with perforated appendicitis

The diagnostic value of serum C-reactive protein (CRP) levels in children with perforated appendicitis was prospectively studied in 78 consecutive patients with histologically confirmed appendicitis. The patients were divided into two groups: group A included 56 patients with perforated appendicitis and group B consisted of 22 patients with simple appendicitis. Serum CRP level and leucocyte count were assayed in all and abdominal ultrasonography was performed in 75. The mean age of group A patients was significantly lower than that of group B patients (7.5 vs. 10.4 years,P<0.001). Group A patients had a significantly higher mean serum CRP levels than group B patients (92 vs. 31 mg/l,P<0.001), while the mean leucocyte count was comparable in the two groups. Of 75 examined patients, 73 (97%) had a pre-operative sonographic diagnosis of appendicitis.     

以发热为主诉的儿童阑尾炎伴穿孔15例临床分析

目的 分析以发热为主诉的儿童阑尾炎伴穿孔的临床特点,以便早期诊断与干预.方法 对15例发热为主诉的儿童阑尾炎伴穿孔患儿的临床资料进行回顾性分析.结果 15例患儿中,院外发热平均(4 6±1.5)d,最高平均体温(39.9±0.5)℃.惊厥3例,腹痛10例,呕吐或恶心12例,腹泻7例,休克2例.入院后穿孔确诊时间平均(45.2±17.4)h.腹部B超提示阑尾周围脓肿和腹腔脓肿分别为7例和2例.平均每例腹部B超检查次数(20±0.7)次.腹部立位平片示肠梗阻8例.外周血WBC＞15×10~9/L者8例.全部病例CRP水平均升高明显,平均(156±35)mg/L.8例检测前降钙素,有5例升高.结论 对儿科急诊发热患儿的评估中,凡遇高热、腹痛、腹胀、腹泻、恶心、呕吐,甚至惊厥者,结合CRP明显升高,需仔细进行腹部查体,必要时多次行腹部B超检查、腹部立位平片、腹部穿刺检查,以排除阑尾炎穿孔可能.     

Percutaneous drainage of intra-abdominal abscess in children with perforated appendicitis

Background

Because the surgical management of perforated appendicitis remains controversial, percutaneous catheter drainage (PCD) has gained favor for managing periappendiceal abscess in hemodynamically stable children.

Objective

To determine the safety and effectiveness of PCD in children with perforated appendicitis and to identify any variables of prognostic value.

Materials &; methods

We retrospectively evaluated clinical data and imaging features for 33 children undergoing PCD for periappendiceal abscess from October 2006 to February 2010. Those with preprocedural CT studies were assigned to one of three risk categories based on imaging features.

Results

Appendectomy was successfully postponed for all patients. Our technical success rate was 87.9%, with three recurrences (two requiring repeat drainage, one managed conservatively) and one possible complication (enterocutaneous fistula formation). Children with large and diffuse abscesses had a 50% rate of technical failure, which was significantly increased when compared to children with large but localized abscesses (P?Conclusion PCD can be effective for managing perforated appendicitis in children. Children with large and ill-defined abscess might be at increased risk for complication or recurrence.     

The utility of peritoneal drains in children with uncomplicated perforated appendicitis

Peritoneal drainage in children with uncomplicated perforated appendicitis (UPA) is still controversial. Many pediatric surgeons prefer not to drain the peritoneal cavity in such cases. However, there is no randomized controlled study performed in children. We aimed to study the effects of peritoneal drainage in children with UPA in a randomized prospective trial. One hundred and forty consecutive patients with UPA were divided randomly into 2 groups. Group I (70 patients) consisted of cases with peritoneal drainage, and group II (70 patients) without drainage. UPA is defined as perforated appendicitis with no more discoloration of peritoneal fluid after peritoneal wash out. Cases with localized abscess in the peritoneum were excluded from the study. In all patients, the ages, duration of symptoms, nasogastric drainage and hospitalization, and complications after surgery were recorded. The duration of hospitalization and nasogastric draining time were significantly lower in patients without peritoneal drainage. There was no difference in postoperative complications between the two groups. The onset of oral intake after surgery was significantly earlier in group II patients. Placing drains in the peritoneum does not improve outcome in UPA. Therefore, we do not recommend routine drainage of children with UPA.     

Interval appendectomy in perforated appendicitis

The treatment of the perforated appendix remains controversial, with the optimal timing of surgical intervention unclear. Previous studies have documented an increase in both minor and major complication rates in patients undergoing appendectomy for perforated appendicitis. We sought to evaluate the nonoperative therapy of perforated appendicitis followed by interval appendectomy. The charts of all children undergoing admission for appendicitis during a 10-year period (n = 480) were reviewed. Data were abstracted regarding patient presentation, laboratory and radiologic findings, operative and pathology reports, and postoperative course in those patients with perforated appendicitis (n = 104). Comparisons were made between patients undergoing primary appendectomy for perforated appendicitis (n = 87) and those treated with IV antibiotics and hydration and then scheduled for interval appendectomy 4 to 6 weeks following the acute event (n = 17). Treatment assignment was determined by the attending pediatric surgeon in a non-randomized fashion. No significant differences were seen between these two groups in days of antibiotic treatment, nasogastric decompression, and IV hydration. Additionally, total hospital days and cost did not differ significantly between the two groups (primary = 10.3 days and $10,550; interval = 13.3 days and $13,221, P = 0.11 and 0.21, respectively). The overall complication rates, 12.6% in the primary group and 5.9% in the interval group, also did not differ significantly, while the major complication rate (wound dehiscence, abscess, and small-bowel obstruction), 10% versus 0%, was significantly higher in the primary group as compared with the interval group. Our data demonstrate no significant disadvantage, and possibly an improvement in the major complication rate, with nonoperative treatment of perforated appendicitis followed by interval appendectomy. We suggest that this treatment modality should be considered when evaluating the child with perforated appendicitis.Presented at the Surgical Section, American Academy of Pediatrics, Washington, DC, USA, 30 October–4 November 1993     

Determinants of postoperative abscess occurrence and percutaneous drainage in children with perforated appendicitis

Purpose

Postoperative abscesses after perforated appendicitis have no clear risk factors or indications for percutaneous drainage. Our study addressed these two issues.

Methods

A logistic regression model was used to delineate risk factors for postoperative abscess in children with perforated appendicitis treated during a recent 5-year period. Drainage of abscess was compared to antibiotic treatment.

Results

Postoperative abscess occurred in 42 (14.8 %) of 284 patients. Higher WBC count, presence of bowel obstruction at presentation, diffuse peritonitis with a dominant abscess at surgery, and one specific surgeon were significantly associated with postoperative abscess, while fever or pain requiring narcotics at the time of abscess diagnosis was significantly associated with drainage. Compared to non-drainage, those drained had longer hospital stay including readmissions (15.9 ± 5.3 vs. 12.2 ± 4.6 days, p < 0.005) and less readmissions (9.5 vs. 33.3 %, p = 0.06). Over the 5-year period, there was no increased trend in abscess occurrence (p = 0.56), but there was an increased trend in the use of percutaneous drainage (p = 0.02).

Conclusions

The risk of a postoperative abscess can be predicted by specific clinical characteristics, surgical findings, and treatment-related factors. Percutaneous drainage was associated with longer hospital stays, but less readmissions.     

Pylephlebitis due to perforated appendicitis in a teenager

Pylephlebitis, a septic thrombophlebitis of the portal vein, is a life-threatening complication of intraabdominal infections, commonly associated with acute appendicitis in children, and diverticulitis in adults. A 13-year-old boy was admitted for high fever and jaundice. On the fifth day of hospitalization, ultrasound Doppler flow and Computer Tomography scan studies showed thrombosis of the portal vein and acute appendicitis. The patient was treated with antibiotics, anticoagulation and laparotomy with appendectomy. No thrombophilic risk factors were diagnosed. Our aim is to improve physicians’ awareness of this complication and emphasize the importance of early diagnosis and appropriate therapy in children in order to reduce serious complications and long-term sequels.     

术前超声评估可疑阑尾炎123例分析

目的通过与儿童阑尾炎评分进行比较,探讨术前超声检查可疑阑尾炎患儿的准确性,及对降低阑尾阴性切除率和穿孔率的价值。方法回顾性分析123例经手术治疗的临床可疑阑尾炎患儿的阑尾炎评分及超声检查结果。根据术前是否进行超声检查,将患儿分为超声检查组和直接手术组;计算两组阴性切除率和穿孔率,评估超声诊断阑尾炎的准确性和敏感性。结果123例中,手术证实为阑尾炎115例,为正常阑尾8例。超声检查组阴性切除率为1．1％（1／90）,其诊断阑尾炎的准确率和敏感率分别为97．8％（19／93）、98．9％（89／90）;直接手术组阴性切除率为16．7％（5／30）,两组比较,P=0．004。两组总穿孔率为55．7％,其中超声检查组为50．0％（45／90）,直接手术组为76．0％（19／25）,两组比较,P=0．021。结论超声检查能检出因临床表现不典型而易被临床评分所忽略的阑尾炎,减少阑尾阴性切除率和穿孔率。     

Image-guided drainage of multiple intraabdominal abscesses in children with perforated appendicitis: an alternative to laparotomy

Background Appendicitis is the most common cause of an acute abdomen in children. With perforation, multiple intraperitoneal collections can be seen at presentation. In this situation, surgical treatment alone is rarely effective. Objective To determine the role of image-guided drainage in treating patients with acute appendicitis complicated by multiple intraabdominal collections. Materials and methods A retrospective review of patient charts and interventional radiology records was performed to identify all patients with acute complicated appendicitis treated by multiple image-guided drainage procedures. Data reviewed included the number of drainages and aspirations performed, drain dwell time, the clinical course and temperature profile, and the length of inpatient hospital stay and any complications experienced. Results The study population comprised 42 children with a mean age of 107.6 months. A total of 100 drainage catheters were inserted and 56 aspirations were performed. Of the 42 children, 24 were successfully treated at a single sitting, while 18 returned for further intervention. The mean drain dwell time was 8.18 days. The mean inpatient stay was 15.02 days. Treatment of the acute presentation with image-guided intervention was successful in 92.3% of children. Conclusion Successful management of acute perforated appendicitis with multiple intraabdominal abscesses can be achieved with multiple minimally invasive image-guided drainage procedures.     

Seasonal variations in weight of children attending an under-fives clinic in Lesotho

The incidence of weight loss between successive visits, prevalence of under centile 3 weight-for-age and over centile 97, showed a marked bimodal annual variation for 1243 children attending an under-fives clinic. 9949 weighings on 661 boys and 682 girls over a five year period, contributed to the database. Season of birth also significantly influenced the centile distributions of weight-attained-for-age. Children over 1 1/2 years old showed considerably higher rates of weight loss (about 1 in 5 children attending in their fifth year of life), than children younger than the mean age of weaning. The rates of weight loss, together with seasonal variation, was considerably higher for a group of 'Regular Attenders' to the clinic, than for a group of 'Low Attenders'. Seasonal influences on growth need to be taken into accounts in evaluating the quality of care and outcome produced by under-fives clinics.