小儿急性阑尾炎早期诊断与治疗

小儿急性阑尾炎是小儿外科常见的急腹症之一，一般来说病势较成人严重，年龄越小临床症状越不典型，短时间内就会出现穿孔造成严重的并发症。因此，如何提高早期诊断水平，使小儿急性阑尾炎得到及时处理，确属一实际问题。现结合我院1995年收治的298例小儿急性阑尾炎，讨论早期诊断与治疗。一、临床资料1995年我院收治小儿急性阑尾炎298例，男199例，女99例，男女之比近2∶1。5岁以下45例，6～10岁125例，11～15岁128例。病理分型：单纯性阑尾炎131例（44％），化脓性阑尾炎128例（43％），穿孔性阑尾炎39例（13％）。全部病例主要临床症状…     

腹内压测定诊断小儿急性阑尾炎的意义

急性阑尾炎是小儿最常见的急腹症 ,因小儿病史不确切 ,检查不合作 ,明确诊断有一定困难 ,为避免不必要的手术及延误手术致并发症发生 ,提高诊断正确率 ,笔者采用了经直肠间接测腹内压 (intraabdominalpressure,IAP)作为小儿急性阑尾炎的辅助诊断方法 ,现就其临床意义作一探讨。资料和方法一、临床资料2 0 0 1年 6月～ 2 0 0 2年 5月我院经手术和病理检查确诊为阑尾炎的 4 0例患儿 ,术前及术后 1d测IAP。根据手术结果分二组 :急性阑尾炎未穿孔组 ,男10例 ,女 9例 ,3～ 14岁 ,平均年龄 (8.4 2± 3.34)岁 ;急性阑尾炎穿孔组 ,男 12例 ,女 9…     

儿童大网膜扭转1例

儿童大网膜扭转临床罕见，可分为原发性和继发性。均可引起明显的腹痛及胃肠道症状，极易误诊为其他急腹症，术前很少能明确诊断，往往以阑尾炎、胆囊炎等施行剖腹探查术而确诊。我们于2013年3月收治1例术前诊断为急性阑尾炎，术中发现为大网膜扭转的病例，现总结如下：     

B超在小儿急性阑尾炎诊治中的应用

Ｂ超在小儿急性阑尾炎诊治中的应用于鼎１９８８年５月～１９９３年５月对１２３例临床诊断为小儿急性阑尾炎的患儿在术前辅以Ｂ超诊断。其中临床误诊２５例，Ｂ超追踪观察排除阑尾炎２１例。术后确诊的１０２例阑尾炎患儿术前经Ｂ超检查，其中９８例显影结果与手术所见及...     

降钙素原在儿童急性阑尾炎及肠系膜淋巴结炎诊治中的评价

目的：探讨血清降钙素原（PCT）在鉴别儿童急性阑尾炎及肠系膜淋巴结炎中的意义。方法回顾性分析2008年7月至2013年7月我们收治的儿童急性阑尾炎（为阑尾炎组）和急性肠系膜淋巴结炎（为肠系膜淋巴结炎组）患儿临床资料。其中阑尾炎组42例，急性肠系膜淋巴结炎组36例，比较两组治疗前后 PCT、C —反应蛋白（CRP）和白细胞计数（WBC），以及这三种指标诊断的特异性、敏感性、阳性预测值和阴性预测值。结果治疗前急性阑尾炎组 PCT 检测结果明显高于正常值，而急性肠系膜淋巴结炎组 PCT 检测结果基本正常，且两组差异有显著统计学意义（P ＜0．01）；治疗3 d 后两组PCT 检测结果均基本正常，差异无统计学意义（P ＞0．05）；以 PCT ＞0．5 ng／mL 作为诊断指标时，特异性、敏感性、阳性预测值、阴性预测值均高于 CRP 及 WBC。结论早期检测 PCT 有助于儿童急性阑尾炎与肠系膜淋巴结炎的鉴别诊断。     

小儿阑尾炎误诊分析

目的 分析小儿阑尾炎的误诊原因，降低小儿阑尾炎的误诊率，减少术后并发症的发生。方法 回顾我院外科1997～2002年误诊的225例急性阑尾炎的临床资料，通过对其病史、手术所见，实验室及辅助检查结果进行回顾性研究，分析误诊原因。结果术前诊断为其他疾病，手术确诊为阑尾炎的163例；术前诊断为阑尾炎，手术证实为其他疾病的62例。全部病例均经手术治疗，术后痊愈出院，并发症的发生率为16.44％。结论 对小儿急性阑尾炎的临床症状特点缺乏足够的认识，腹部体征的掌握不准确及过多的依赖辅助检查是误诊的主要原因。对酷似阑尾炎的病例，应当允许阑尾误切的存在，但应注意诊断和鉴别诊断，尽量减少误切。     

逐步加压超声诊断小儿急性阑尾炎的价值

目的 评价逐步加压超声诊断小儿急性阑尾炎的价值及影响因素.方法 对拟急性阑尾炎行剖腹手术,且术前72 h经同一医师超声检查的104患儿进行超声声像与手术病理结果 对比.结果 逐步加压超声对小儿急性阑尾炎的检出率为91.26%,1～4岁、～9岁、～15岁患儿的检出率分别为100.00%、92.16%和87.50%.结论 逐步加压超声可有效地解决小儿特别是幼儿急性阑尾炎临床诊断的困难.     

改良Alvarado评分系统与小儿阑尾炎术后病理的相关分析

目的　为探讨改良Alvarado评分系统与小儿急性阑尾炎术后病理结果的相关关系 ,以及在小儿急性阑尾炎诊断中的应用。方法　评估上海第二医科大学附属新华医院上海儿童医学中心外科 2 0 0 1年 1月至 2 0 0 3年 6月间收治 ,拟诊急性阑尾炎并施行阑尾切除术的 2 4 8例患儿临床资料 ,对Alvarado系统评分结果与病理诊断进行分析。结果　评分系统与病理分级呈正相关 (r =0 .4 30 ,P<0 .0 1) ;在预测进展型病理的阑尾炎病例时 ,评分系统的灵敏度为 82 .3% ,特异度为 77.0 %。结论　提示改良Alvarado评分系统在早期诊断小儿急性阑尾炎与确定外科手术治疗 ,减少非必要性急诊手术率和穿孔的危险上有重要价值。     

急诊疑似阑尾炎VCT平扫与术后病理诊断对照准确性研究及影像学特征

目的以手术和病理诊断为金标准,探讨VCT平扫对急诊疑似阑尾炎的诊断价值。方法 2008年6月至2009年5月对急诊疑诊阑尾炎患儿行VCT平扫检查,与随后进行的外科手术病理学检查结果对照。统计分析VCT平扫诊断的准确性、敏感度、特异度、阴性似然比及阳性似然比。并分析急性阑尾炎和其他急腹症的VCT影像学特征。结果 284例患儿中手术和病理学检查诊断急性阑尾炎270例,VCT平扫诊断急诊阑尾炎243例。VCT平扫对急诊阑尾炎的诊断准确性为90%(95%CI:87%～92%)、敏感度为0.91(95%CI:0.87～0.94)、特异度为0.89(95%CI:0.85～0.93)。进一步根据阑尾炎病理学检查结果行亚组分析,结果显示,急诊单纯性阑尾炎的VCT诊断准确性为62.3%,急诊化脓性、坏疽性和穿孔性阑尾炎的诊断准确性均95%。漏诊和误诊的27例急诊阑尾炎中,包括23例单纯性阑尾炎,4例化脓性阑尾炎(3例被误诊为盆腔右侧附件病变,1例被误诊为右侧输尿管下端结石)。284例中14例为其他原因急腹症,VCT平扫准确诊断11例(78.7%),漏诊3例,包括肠系膜裂孔疝、梅克尔憩室扭转及索带压迫各1例。急性阑尾炎患儿典型的VCT特征为阑尾周围脂肪间隙模糊,阑尾增粗(直径为5～19mm),阑尾壁增厚。结论 VCT平扫对于急诊疑似阑尾炎的诊断具有显著意义,但对于单纯性阑尾炎的诊断准确性较低,必要时应行增强VCT检查以提高诊断准确性。     

儿童急性阑尾炎血清免疫抑制酸性蛋白测定及其临床意义

了解儿童急性阑尾炎血清免疫抑制酸性蛋白表达水平及其临床意义。方法选取７０例正常对照和１３２例急性阑尾炎病例，应用琼脂单向免疫扩散法检测术前血清ＩＡＰ水平。结论ＩＡＰ可作为衡量急性阑尾炎症反频程度及机体免疫状态的血清学指标，提示随阑尾炎症的加重，机体免疫抑制状愈明显。     

The diagnosis of appendicitis in childhood]

89 preschool children, 2-4 years old, treated under the diagnosis of appendicitis were analyzed. 46 of them were operated. In 39% of those children the diagnosis of an acute nonperforated appendicitis could have been ensured, in 39% the diagnosis of a perforated appendicitis was found, in 22% the was found, in 22% the laparotomy was negative. In cases of an acute perforated appendicitis typical symptoms were vomiting (100%), general stomach-ache (89%) and fever (61%). In most cases of an perforated appendicitis the state of patients was reduced drastically (80%), in 50% an ileus could be observed. Half a children with an acute nonperforated appendicitis as well as an perforated appendicitis had got a respiratory disease additionally. This fact was the main reason for the to late diagnosis particularly in the age up to 3. In all cases being not sure a consequent control at a ward is necessary; an important fact for this recommendation is the shortness of the acute perforated appendicitis in early childhood.     

Appendicitis after blunt abdominal trauma in the pediatric patient — fact or fancy?

At the Hospital for Sick Children, Toronto, about 300 children a year are operated on with the diagnosis of acute appendicitis. In four such cases in the last 15 years blunt abdominal trauma preceded the acute appendicitis. The four children (three boys and one girl) ranged from 6 to 15 years. Within 7 days of the blunt abdominal trauma the patients developed signs and symptoms of peritonitis requiring laparotomy. They all had an appendectomy for acute appendicitis; one boy also had 150 ml of old blood from a splenic hematoma. Although any child who has suffered blunt abdominal trauma and then slowly develops peritoneal signs in the lower abdomen may be suspected of having acute appendicitis, it seems reasonable to assume that this sequence of events is more coincidence than real.     

Appendicitis in children less than 3 years of age: a 28-year review

Appendicitis is the most common surgical abdominal emergency in the pediatric population, but is rarely considered in children less than 3 years of age. The goal of this study was to identify the presenting symptoms and signs in this age group and examine their subsequent management and outcome. A 28-year experience of a single pediatric surgeon in academic practice was reviewed; 27 children less than 3 years old (mean 23 months) comprised 2.3% of all children with appendicitis in his series. The most common presenting symptoms were vomiting (27), fever (23), pain (21), anorexia (15), and diarrhea (11). The average duration of symptoms was 3 days, with 4 or more days in 9 children. Eighteen children were seen by a physician before the correct diagnosis was made; 14 were initially treated for an upper respiratory tract infection, otitis media, or a urinary tract infection. The most common presenting signs were abdominal tenderness (27), peritonitis (24), temperature 38.0 °C or more (21), abdominal distension (18), Leukocytosis (<12.0 × 10³/mm³) was found in 18, tenderness was localized to the right lower quadrant (RLQ) in 14 and was diffuse in 10. Abdominal radiographs demonstrated findings of a small-bowel obstruction (SBO) in 14 of 21 patients, a fecalith in 2, and a pneumoperitoneum in 1. Contrast enemas were performed in 6 children, 5 of whom had a phlegmon or an abscess. Perforated appendicitis was found in all 27 patients. An appendectomy was performed in 25 and a RLQ drain was placed in 18. Postoperative antibiotics were administered to 17 children for an average of 6 days. Two patients underwent interval appendectomies, 1 following treatment with IV antibiotics and 1 following surgical drainage. The average time to resume oral intake was 7 days and the average hospital stay was 21 (median 15) days. Sixteen patients had 22 complications, which included 6 wound infections, 4 abscesses, 4 wound dehiscences, 3 pneumonias, 2 SBOs, 2 incisional hernias, and 1 enterocutaneous fistula. Perforated appendicitis was found in all children less than 3 years old, resulting in very high morbidity (59% complications), which may be attributed to the 3–5-day delay in diagnosis. Although appendicitis is uncommon in this age group, it should be seriously considered in the differential diagnosis of children under the age of 3 years who present with the triad of abdominal pain, tenderness, and vomiting.     

小儿阑尾炎早期诊断的临床研究——30年10256例小儿阑尾炎经验总结

目的总结连续30年10256例小儿阑尾炎的诊断治疗经验,提出早期诊断的临床标准,为早期手术治疗提供依据,以降低病死率,减少并发症。方法统计1980年至2009年本院收治的小儿阑尾炎病例10256例,使用32项临床指标进行对比研究,提出核心诊断指标指导临床早期诊治。在新的理念指导下,分析前10年及后20年,阑尾炎病例在腹膜炎的发生率以及阑尾炎病理类型上的变化,探讨早期诊断标准在提高阑尾炎诊治水平方面的实际意义。结果10256例阑尾炎病例中,死亡1例,死亡率小于1／10000。8241例阑尾炎病例的有效统计中,持续性右下腹疼痛或伴哭吵不安症状的患儿8131例（98．67％）,右下腹固定压痛8103例（98．33％）。实施早期诊断标准后,阑尾炎穿孔形成腹膜炎的发生率从早期的43．82％降低为29．88％。10256例中,595例为婴幼儿阑尾炎,466例并发阑尾周围脓肿。结论持续性右下腹疼痛及右下腹固定压痛是临床诊断小儿阑尾炎的核心指标,既是必要的,也是充分的。小儿阑尾炎的临床早期诊断是提高治愈率,减少并发症的关键。     

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.     

The evaluation of the validity of Alvarado,Eskelinen, Lintula and Ohmann scoring systems in diagnosing acute appendicitis in children

Purpose

To show whether Alvarado, Eskelinen, Lintula and Ohmann scoring systems have predictive values in diagnosing acute appendicitis in children.

Methods

Sixty patients with suspected acute appendicitis were prospectively evaluated. Alvarado, Eskelinen, Lintula and Ohmann scores were calculated separately for each patient at the time of admission. The specificity, sensitivity, positive and negative predictive values of the scores were calculated. The predictive value of the scores was evaluated with the receiver operating characteristic (ROC) curve and the consistency among the scores by Kappa test.

Results

Twenty of the patients were female (33.3 %). The mean age of the patients was 9.9 years (3–16 years). Forty two patients were operated and appendectomies were performed with the diagnosis of acute appendicitis. The area under the ROC curve showed that the scores had no predictive value in diagnosing acute appendicitis. Kappa test showed that agreement between the scores was not good.

Conclusion

The sensitivity and specificity of the four scoring systems were not sufficient enough in diagnosing acute appendicitis in our patient group. We concluded that the most important factor affecting the decision for surgery in suspected acute appendicitis is the surgeon’s experience combined with physical findings of repeated clinical examinations.     

74例小儿慢性阑尾炎诊断分析

目的总结小儿慢性阑尾炎的特点及诊断方法。方法回顾性分析2000年1月￣2004年12月经手术治疗并确诊的74例慢性阑尾炎患儿的症状、发病及诊断过程。结果74例均临床诊断为慢性阑尾炎,占5.79%;全部病例均行阑尾切除术,其中43例(3.36%)病理诊断为慢性阑尾炎。结论小儿慢性阑尾炎并不少见,除反复发作的腹痛病史外,阑尾慢性粘连及阑尾粪石是诊断慢性阑尾炎的重要依据。     

Graded compression ultrasonography in the assessment of the “tough decision” acute abdomen in childhood

The diagnosis of acute appendicitis in childhood is frequently difficult. In some situations the need to operate is clear, but in others the decisions may be much “tougher” because the clinical findings are equivocal. This is a retrospective study of a consecutive series of 253 children presenting with “acute abdominal pain? appendicitis” who had graded compression ultrasonography (GCUS) because the clinical scenario did not warrant immediate laparotomy. This represents 30% of all cases seen in the study period. The aim of the study was to examine the role of GCUS and a clinical scoring system (the Alvarado score) in patients in whom the diagnosis is uncertain.     

Neurogenic appendicopathy in children.

BACKGROUND: In a prospective multicenter study, we could show that neurogenic appendicopathy is a histological entity. This study compares the general and the pediatric population with respect to clinical presentation and incidence of neurogenic appendicopathy (NA). METHODS: Included were patients that underwent appendectomy for suspected appendicitis, excluded were patients younger than 6 years and patients with missing data. Neurogenic appendicopathy was diagnosed by S-100 immunochemistry and/or haematoxylineosin (H.E.) staining. Two age groups (< or = 14 y and > 14 y) were compared with respect to the frequency of NA. RESULTS: In only four cases out of 84 children (4.8%) did we find neurogenic appendicopathy compared to 48 patients (24.2 %) out of 198 adolescents and adults. In the subgroup with negative appendectomy, the frequency of NA was 16.7% (< or = 14 years) and 56.6% (> 14 years). A clinical differentiation between neurogenic appendicopathy and acute appendicitis was not possible because of the small sample size. CONCLUSION: Neurogenic appendicopathy is a very rare histopathological entity in children. History and clinical examination do not make it possible for us to differentiate preoperatively between acute appendicitis and neurogenic appendicopathy.     

小儿急腹症中的妇科问题

目的：分析小儿妇科疾病引起的急腹症的特征及临床误诊原因，并提出避免误诊的方法。方法：回顾我院外科1990－2001年以急腹症为主要表现的女性小儿生殖系统病例20例，年龄2－14岁，平均10．2岁。其中：卵巢囊肿4例，卵巢畸胎瘤7例，卵巢恶性卵黄囊肿1例，黄体破裂3例，处女膜闭锁2例，盆腔炎2例，原发性痛经1例，结果：术前误诊4例，黄体破裂误诊为阑尾炎2例，卵巢囊肿误诊为阑尾炎1例，处女膜闭锁误诊为盆腔包块1例，手术治疗16例，抗炎止血等保守治疗3例，解痉止痛1例，全部病例均痊愈出院。结论：小儿妇科急腹症分为破裂性疾病，肿瘤和炎症，幼童期1－9岁以肿瘤性疾病为主，青春期9岁以后即要考虑特有疾病如处女膜闭锁以及黄体破裂等，术前要了解科情况，诊断急性阑尾炎有疑问但又确有手术指征时，可以采取腹直肌纵切口。除非证实肿瘤为恶性，否则应尽量保留卵巢。