改良Alvarado评分系统在小儿阑尾炎诊断中的应用

目的　探讨改良Alvarado评分系统在小儿阑尾炎诊断中的应用价值。方法　用改良Alvarado评分系统评估我院自2001年6月至2006年6月经手术证实并治疗14岁以下小儿阑尾炎患者共208例,对评分结果与病理诊断进行分析。结果　评分分值与病理分级成正相关（r=0.510,P〈0.01）。结论　提示改良Alvarado评分系统在诊断小儿急性阑尾炎与确定外科手术治疗上有一定价值。     

改良Alvarado评分对急性阑尾炎的诊断价值分析

目的 探讨改良Alvarado评分对急性阑尾炎诊断和治疗价值.方法 回顾我院自1985年1月至2009年12月间收治的行阑尾切除术并有完整临床资料的患者1637例,计算改良Alvarado评分,比较评分≥7分患者（833例）及＜7分患者（804例）的阴性切除率;计算评分的阳性预测率;并对评分结果和病理诊断进行相关分析.结果 评分≥7分患者阴性切除率明显低于评分〈7分患者,差异有统计学意义;评分阳性预测率为93.8%;评分分值和病理分型成正相关（r=0.637,P〈0.01）.结论 应用改良Alvarado评分能提高急性阑尾炎的诊断率,显著降低阴性阑尾切除率.     

Alvarado scoring system in prediction of acute appendicitis

Objective: To evaluate the diagnostic accuracy of Alvarado score for the prediction of acute appendicitis. Study Design: Analytical study. Place and Duration of Study: This study was carried out in the Department of Surgery, Pakistan Institute of Medical Sciences (PIMS), Islamabad, during the period from January 15, 2009 to July 15, 2010. Methodology: The study included all adult patients of either gender who presented with clinical findings suggestive of acute appendicitis, who were assigned Alvarado score of < 4 pre-operatively and subsequently underwent emergency appendicectomy with histological examination of the resected specimens. Based on the Alvarado score, the patients were stratified into two groups. i.e. Group I (with a score of > 7) and Group II (with a score of 5-7). Alvarado score was compared with the histopathology. The data was subjected to statistical analysis to measure the objective. Results: The overall sensitivity, specificity, positive predictive value and negative predictive value of Alvarado score for acute appendicitis were 66%, 81%, 96%, 29% respectively. The sensitivity was higher though not significant, for males with a score over 7 than females with similar scores (97% vs. 92%). However, for scores less than 7, sensitivity among males was significantly higher than females with similar scores (79% vs. 61%; p < 0.05). Conclusion: The presence of a high Alvarado score in adult males is highly predictive of acute appendicitis, however, in women of child bearing age other causes of similar clinical presentation lead to a low diagnostic accuracy of the score.     

A pre-operative clinical scoring system to distinguish perforation risk with pediatric appendicitis

Importance

Appendicitis is a common, potentially serious pediatric disease. An important factor in determining management strategy [whether/when to perform appendectomy, duration of antibiotic therapy/hospitalization, etc.] and predicting outcome is distinguishing whether perforation is present.

Scoring system for computer-aided diagnosis of acute appendicitis. The value of prospective versus retrospective studies

The high negative exploration rate in patients with suspected acute appendicitis is the main compelling reason to improve the accuracy in managing patients with acute abdominal pain. In this article, data from a prospective study on a group of patients undergoing an acute appendectomy were used to devise a scoring system for the purpose of differentiating between the patients with an acute appendicitis and those found to have a normal appendix at operation. The results show that by using the scoring system described, 30% of the unnecessary appendectomies could have been avoided. These findings show the potential value of this method. The results of the prospective study were compared with the results of a retrospective study on the same group of patients demonstrating a significant difference and hence the unreliability of retrospective studies.     

Accurate diagnosis of acute appendicitis: a retrospective and prospective analysis of 686 patients.

OBJECTIVE--To formulate a score system that would make the preoperative diagnosis of acute appendicitis more accurate. DESIGN--Retrospective then prospective study. SETTING--City University Hospital. SUBJECTS--536 patients who had their appendixes removed between 1981 and 1986 (retrospective study), and 150 consecutive patients admitted with a presumptive diagnosis of appendicitis between 1987 and 1988 (prospective study). MAIN OUTCOME MEASURES--Correlation between the histological diagnosis of appendicitis and variables representing history, clinical examination, and laboratory investigations. RESULTS--The rate of histologically proven negative appendicectomies in the retrospective series was 40% and in the prospective series 33%. The variables that were thought to be predictive were: male sex, white cell count of greater than 11 x 10(9)/l, history of less than 24 hours with no previous complaints, rebound tenderness, shift of pain from the epigastrium, and localised guarding, but all criteria had low specificities and sensitivities when applied prospectively, and combining the scores did not improve them. CONCLUSION--The accurate diagnosis of appendicitis depends largely on the experience of the surgeon and is not improved by the application of a score system that includes the above variables.     

Utility of white cell count and ultrasound in the diagnosis of acute appendicitis

Background: Despite considerable advances in imaging, the diagnosis of acute appendicitis remains a clinical one. Nonetheless, knowledge of the characteristics of commonly used investigations for appendicitis may aid surgical decision‐making. Methods: The pathology, full blood counts and ultrasounds of 1013 patients who underwent appendicectomy were reviewed and subjected to statistical analysis in order to determine diagnostic characteristics of various white cell count and ultrasound results. Results: Total white cell count was found to be higher among patients with complicated appendicitis than those with simple appendicitis or normal appendices. Ultrasound was found to be less accurate than white cell count and neutrophil count in the diag­nosis of acute appendicitis by estimation of area under the receiver operator characteristic curve. Conclusion: Knowledge of the meaning of various white cell count values may be invaluable in clinical decision‐making with regard to the diagnosis of acute appendicitis. Ultrasound is of limited utility in the diagnosis of appendicitis and should only be used in selected clinical situations.     

Routine use of a scoring system for decision-making in suspected acute appendicitis in adults

Clinical data from 259 patients with suspected acute appendicitis were prospectively collected and used in construction of a Bayesian scoring system, comprising 19 attributes, for preoperative diagnosis. The scoring system was integrated into the routine clinical management of a prospective series of 830 patients. Laparotomy was performed in 310 cases, and of these 256 had acute appendicitis (perforation in 14%). Excluding 6 cases with normal appendix but laparotomy mandatory for other reasons, the negative laparotomy rate was 15.5%. This rate was significantly lower than in earlier series from the same hospital and in more than 8,000 appendectomies performed in Sweden since 1969. The scoring system had 90.2% sensitivity, 91.4% specificity, 82.5% positive predictive value and 95.4% negative predictive value. The system is regarded only as an aid in diagnosis, to be used in combination with clinicians' judgements. Construction of a local data base probably is essential for results equivalent to those here reported.     

Utility of immature granulocyte percentage in pediatric appendicitis

Background

Acute appendicitis is the most common cause of abdominal surgery in children. Adjuncts are used to help clinicians predict acute or perforated appendicitis, which may affect treatment decisions. Automated hematologic analyzers can perform more accurate automated differentials including immature granulocyte percentages (IG%). Elevated IG% has demonstrated improved accuracy for predicting sepsis in the neonatal population than traditional immature-to-total neutrophil count ratios. We intended to assess the additional discriminatory ability of IG% to traditionally assessed parameters in the differentiation between acute and perforated appendicitis.

Materials and methods

We identified all patients with appendicitis from July 2012–June 2013 by International Classification of Diseases-9 code. Charts were reviewed for relevant demographic, clinical, and outcome data, which were compared between acute and perforated appendicitis groups using Fisher exact and t-tests for categorical and continuous variables, respectively. We used an adjusted logistic regression model using clinical laboratory values to predict the odds of perforated appendicitis.

Results

A total of 251 patients were included in the analysis. Those with perforated appendicitis had a higher white blood cell count (P = 0.0063), C-reactive protein (CRP) (P < 0.0001), and IG% (P = 0.0299). In the adjusted model, only elevated CRP (odds ratio 3.46, 95% confidence interval 1.40–8.54) and presence of left shift (odds ratio 2.66, 95% confidence interval 1.09–6.46) were significant predictors of perforated appendicitis. The c-statistic of the final model was 0.70, suggesting fair discriminatory ability in predicting perforated appendicitis.

Conclusions

IG% did not provide any additional benefit to elevated CRP and presence of left shift in the differentiation between acute and perforated appendicitis.     

Peritoneoscopy for the diagnosis of acute appendicitis in females of reproductive age

Summary The diagnosis of acute appendicitis in women of reproductive age can be a difficult clinical problem. A retrospective audit found our incidence of normal appendix removal in this patient population to be 42%. This study was undertaken to determine if the selective use of peritoneoscopy would improve the accuracy of diagnosis and thereby reduce the need for celiotomy in these patients. Peritoneoscopy was performed on 21 patients, and acute appendicitis was confirmed in 12 cases. Tubo-ovarian pathology was found in 5 patients, no pathology was found in 4 patients, and an unnecessary celiotomy was avoided in 8 patients. The incidence of normal appendix removal was reduced to 15%. There were no serious complications associated with peritoneoscopy. Diagnostic peritoneoscopy should be liberally employed in women of reproductive age with suspected appendicitis.The views expressed in this article are those of the authors and do not reflect the official policy or position of the Department of the Navy, Department of Defense, nor the US Government     

Hyponatremia as a predictor of perforated acute appendicitis in pediatric population: A prospective study

BackgroundThe aim of this study was to investigate hyponatremia as a new biochemical marker associated with complicated appendicitis in the pediatric population.MethodsPediatric patients (n = 184) with acute appendicitis confirmed by histopathology were enrolled in a prospective cohort study from January 2019 to May 2020. Medical history, demographic and clinical data were recorded in the study protocol. Blood samples for biochemical analysis, electrolytes and acute inflammatory markers were taken before surgery.Patients were further divided in two groups, those with non-perforated (n = 148; 79%) and perforated appendicitis (n = 38; 21%).ResultsThe mean serum sodium level in patients with complicated appendicitis was significantly lower compared to patients with non-complicated appendicitis (132.2 mmol/L vs. 139.2 mmol/L, p < 0.001). The receiver operating characteristic curve of plasma sodium concentration in patients who were diagnosed with perforated acute appendicitis showed an area under the curve of 0.983 (95% CI, 0.963–1.00). A cut-off-value of plasma sodium concentration of ≤ 135 mmol/L was shown to give the best possible sensitivity and specificity, 94.7% (95% CI: 82.2–99.3) and 88.5% (95% CI: 88.2–93.2) respectively (p < 0.001). Patients with complicated appendicitis were more likely to be younger than five years of age (10.5% vs. 1.4%, p = 0.005), have a duration of symptoms for > 24 h (97.4% vs. 59.6%, p < 0.001), sodium serum concentration ≤ 135 mmol/L (89.5% vs. 5.5%, p < 0.001), body temperature > 38.5 °C (47.4% vs. 11.0%, p < 0.001) and CRP serum concentration > 62 mg/L (26% vs. 2%, p < 0.001).ConclusionHyponatremia is a novel and very discriminative marker of complicated appendicitis in the pediatric population, and is therefore recommended in appendicitis diagnostic and treatment planning.Type of studyProspective comparative studyLevel of evidenceII     

Evaluation of the modified Alvarado score in the diagnosis of acute appendicitis: a prospective study.

The Alvarado score was assessed as to its accuracy in the preoperative diagnosis of acute appendicitis. A series of 49 consecutive patients was studied prospectively over a period of 9 months in two hospitals (Gateshead and Sunderland). The presence of a high score was found to be an easy and satisfactory aid to early diagnosis of appendicitis in children and men. However, the false-positive rate for appendicitis in women was unacceptably high.     

Wound infection prophylaxis in pediatric acute appendicitis: a 26-year prospective study

Purpose

The purpose of this study was to determine the best wound infection prophylaxis in pediatric acute appendicitis.

Methods

From 1969 to 1995 inclusive, 453 consecutive pediatric patients at the same children's hospital had an appendix with acute inflammation (acute appendicitis) removed by the same staff surgeon and his resident. The stump was not inverted, and chromic catgut was used throughout. No intraperitoneal antibiotics, irrigation, or drains were used, and the skin closure was with silk sutures initially and then with staples since 1986. The infants and children were divided into 6 consecutive groups of 52 to 96 patients, with each group lasting 2 to 5 years. The wound treatment groups were as follows: no treatment, drain or pack, drain or pack plus antibiotic powder, antibiotic powder, preoperative intravenous antibiotic plus antibiotic powder, and preoperative intravenous antibiotic. The wound Penrose drain, one half-inch gauze pack, and/or antibiotic powder (ampicillin, 1977-1981; cefoxitin, 1982-1995) were all placed in the subcutaneous space.

Results

There were a total of 50 (11%) wound infections (pus) that occurred between 4 and 40 days when no antibiotic powder was used and 2 to 14 days with antibiotic powder. In all 6 groups of patients, no organism was grown in most (80%) infections and Escherichia coli was the second commonest (12%). The serous ooze, which occurred only with the use of antibiotic powder (8%), was seen between 6 and 18 days, and no organism was ever cultured.

Conclusions

The patients with preoperative (or intraoperative) intravenous antibiotics (cefoxitin) plus wound antibiotic powder (cefoxitin) had the lowest infection rate (2.5%). When this group was compared with the baseline group 1 (no treatment), it was the only group in which wound treatment made a significant difference (P = .003).     

Aids in the diagnosis of acute appendicitis

Methods used to improve the accuracy of diagnosis of acute appendicitis are reviewed. Laparoscopy, barium enema, ultrasonography and computer assistance have all been shown to improve accuracy, but no one method is of proven superiority. Such diagnostic aids or intensive in-hospital observation must be used to reduce the 15-30 per cent negative laparotomy rate when acute appendicitis is suspected, without increasing the incidence of appendiceal perforation.     

Laparoscopy in the diagnosis of acute appendicitis

The results of diagnosis of acute appendicitis (AA) were retrospectively analyzed in 2403 patients, in 336 of them diagnostic laparoscopy (DLS) was performed. Acute appendicitis was diagnosed in 132 (39.3%) patients, other surgical diseases were found in 102 (20.35%) and acute surgical abdominal diseases of were excluded in 102 (20.35%) patients. AA was also diagnosed in 17 patients suspected for other surgical diseases of the abdomen. This is DLS showed AA in 149 (42.2%) patients and its absence in 204 (57.8%) cases DLS revealed cathartic AA was in 3 (2%) patients, in of 2 of them there was a diagnostic error during morphologic control (no inflammation). The diagnostic error rate was 96% in the group of 163 patients undergone appendectomy for cathartic AA without previous DLS. At DLS destructive AA forms were diagnosed in 111 patients, diagnostic errors were made in 0.9%. In the group of patients undergone appendectomy for destructive AA without previous DLS, the diagnostic errors rate was 1.1%. In 35 cases (23.4%) when the appendix could not be visualized at DLS (including patients with appendiceal infiltrate), the diagnosis was based on indirect criteria, errors being made in 3 cases. There were neither direct nor indirect data on the appendiceal status in 3 (0.9%) DLS. In these cases, the policy was based on clinical manifestations.