Clinical spectrum of acute abdominal pain in Turkish pediatric patients: A prospective study

Abstract Background : The aim of the present study was to determine the prevalence, associated symptoms, and clinical outcomes of children with acute abdominal pain who had been admitted to an emergency department. Methods : Children aged between 2 and 16 years who presented to the emergency department of Cerrahpa?a Medical School, Istanbul University between July 2001 and August 2002 with acute abdominal pain were enrolled in this study. A questionnaire was completed each patient admitted to our pediatric emergency unit for acute abdominal pain. Data collected included presenting signs and symptoms, the hospital follow up for all children who returned within 10 days, test results, and telephone follow up. Results : The number of children referred to the emergency department was 7442, with 399 (5.4%) of these having acute abdominal pain. The mean age of the study population was 6.9 ± 3.5 years, and 201 of the patients were male. The five most prevalent diagnoses were: (i) upper respiratory tract infection and/or complicated with otitis media or sinusitis (23.7%); (ii) abdominal pain with uncertain etiology (15.4%); (iii) gastroenteritis (15.4%); (iv) constipation (9.4%); and (v) urinary tract infection (8%). The most common associated symptoms were decreased appetite, fever and emesis. Because of follow‐up deficiency the progress of 28 patients was not obtained. Eighty‐two children were referred to the department of pediatric surgery, but only 17 of 82 (20.7%) required surgical intervention (15 of these 17 for appendicitis). Eleven patients returned within 10 days for re‐evaluation, but the initial diagnosis was not changed. The complaints of 57 patients with uncertain etiology were resolved within 2 days. Conclusions : An acute complaint of abdominal pain was usually attributed to a self‐limited disease. However, the percentage of surgical etiology is not negligible.     

Diagnosing appendicitis in children with acute abdominal pain

Differentiating acute appendicitis from other causes of acute abdominal pain in children frequently remains unsatisfactory. To determine whether initial historical and physical examination findings might predict final diagnoses, 246 patients with complaints of nontraumatic and nonrecurrent acute abdominal pain were studied. All were between three and 18 years of age and had presented to a hospital-based pediatric emergency department. Each family was telephoned an average of 5.1 days after the visit to determine the patient's subsequent clinical course; operative notes and pathology reports were reviewed for patients receiving surgery. Of these patients with acute abdominal pain, both fever and vomiting were present in 18 of the 24 who eventually had diagnoses of appendicitis, compared with 49 of 222 patients with other final diagnoses (P less than 0.01, with negative predictive value 0.97, sensitivity 0.75, and specificity 0.78, but positive predictive value only 0.27). The duration of the pain at presentation and the frequency of other symptoms (eg, diarrhea, dysuria, anorexia, and lethargy) were unrelated, however, to final diagnosis, as was the duration of the pain and whether abdominal tenderness initially was localized or generalized. Nonruptured appendicitis was generally indistinguishable from ruptured appendicitis preoperatively, by both duration and symptoms. Boys were found more likely to have appendicitis (with or without rupture) than girls (18/118 or 15%, vs. 6/128 or 5%, P less than 0.05). In conclusion, fever and vomiting were noted at presentation more frequently in children with appendicitis than in children with other causes of acute abdominal pain.(ABSTRACT TRUNCATED AT 250 WORDS)     

Appendicitis in infancy

Acute appendicitis is the most common cause of abdominal pain requiring surgery in children. But it is an uncommon entity in young children and rare in infants. During a 10-year period, between January 1991 and December 2000, 7 infants (age from 17 days to 8 months) were treated for acute appendicitis at Changhua Christian Hospital. All of the preoperative symptoms and signs, the duration between admission and operation, pathology reports, and laboratory data were reviewed. There were no specific clinical signs and symptoms. The duration between admission and operation ranged from 2 hours to 5 days (mean: 31.4 hours). The pathology reports revealed 3 were gangrenous, 3 were gangrenous with perforation and one was suppurative. There was one death. Pseudomonas aeruginosa was cultured from blood, ascites, bile or stool in 6 cases (85.7%). Early diagnosis of acute appendicitis in infants is still difficult. Although the mortality has declined, the morbidity still remains high. The high percentage of infection by Pseudomonas aeruginosa should be further evaluated in infantile appendicitis.     

Appendizitis

Appendicitis is the most frequent intraabdominal disease requiring surgical intervention. The clinical presentation can vary from acute abdominal pain to unspecific symptoms such as loss of appetite, fever, nausea and vomiting. The age of maximum frequency for appendicitis is between 6 and 12 years. Diagnosing acute appendicitis can be particularly challenging in young children, where symptoms are uncharacteristic and perforation can occur rapidly. The main factors influencing the outcome of appendicitis include accurate diagnosis followed by appendectomy prior to appendix perforation. Factors contributing to an almost 100% survival rate and a significant reduction in postoperative complications and long-term morbidity include the use of ultrasound and CT, anesthesia and surgical techniques especially suited to children, pediatric intensive care, as well as peri- and postoperative antibiotic therapy.     

Acute abdomen in children due to extra-abdominal causes

Background: Acute abdominal pain in children is a common cause for referral to the emergency room and for subsequent hospitalization to pediatric medical or surgical departments. There are rare occasions when the abdominal pain is derived from extra-abdominal organs or systems. The aim of the present study was to establish the most common extra-abdominal causes of acute abdominal pain.
Methods: The notes of all children (1 month–14 years of age) examined for acute abdominal pain in the Accident and Emergency (A&E) Department of Alexandroupolis District University Hospital in January 2001–December 2005 were analyzed retrospectively. Demographic data, clinical signs and symptoms, and laboratory findings were recorded, as well as the final diagnosis and outcome.
Results: Of a total number of 28 124 children who were brought to the A&E department, in 1731 the main complaint was acute abdominal pain. In 51 children their symptoms had an extra-abdominal cause, the most frequent being pneumonia ( n  = 15), tonsillitis ( n  = 10), otitis media ( n  = 9), and acute leukemia ( n  = 5).
Conclusion: Both abdominal and extra-abdominal causes should be considered by a pediatrician who is confronted with a child with acute abdominal pain.     

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.     

Diagnosing abdominal pain in a pediatric emergency department.

We undertook a prospective study of 377 children (two to 16 years old) presenting with abdominal pain to determine: 1) common discharge diagnoses; 2) what signs and symptoms are associated with appendicitis; and 3) follow-up of patients discharged from the emergency department (ED). Nine diagnoses accounted for 86% of all diagnoses made. The most common final diagnosis was "abdominal pain" (36%). The following findings were significantly associated with appendicitis: vomiting, right lower quadrant(RLQ) pain, tenderness, and guarding (all P less than 0.001). Ninety-seven percent (28/29) of patients with appendicitis had at least two of these four signs and symptoms, as did 28% (96/348) of patients without appendicitis. The sensitivity of the model is 0.96, and the specificity is 0.72 (positive predictive value = 0.24; negative predictive value = 0.99). Of the patients contacted within one week of the visit (237), 75% reported that the pain had resolved (mean contact time, 2.6 days). We conclude that 1) patients presenting to the ED with abdominal pain often leave with the diagnosis of abdominal pain; 2) of the patients contacted, the majority reported that their pain has resolved; and 3) a diagnosis of appendicitis should be considered in any patient with any two of the following signs or symptoms: vomiting, guarding, tenderness, or RLQ pain. Such patients should be evaluated and observed carefully for the possible diagnosis of appendicitis.     

Pathologic Evaluation of Appendectomy Specimens in Children: Is Routine Histopatholgic Examination Indicated?

Objective

Acute appendicitis is the most common cause of abdominal surgery in children. Similarity between signs and symptoms of appendicitis and other common pediatric illnesses, atypical manifestations of appendicitis in young children, and children''s inability to give precise explanation for their symptoms contribute to considerable delay in proper diagnosis and increased rate of perforation. Current study reports the surgical and pathological findings of appendectomies in the largest Children''s Hospital in Iran. It also evaluates whether common protocol for pathologic evaluation following appendectomy is beneficial.

Methods

Pathologic reports of 947 appendectomies, performed with the presumptive diagnosis of acute appendicitis, were gathered. Correlation between surgical and pathologic findings was assessed. Demographic characteristics of patients between surgical and pathological subgroups were also compared.

Findings

The mean age of participants was 6.9±3.5 years. Eighty seven (25.5%) children had abnormal pathological findings and normal surgical report. None of miscellaneous findings including appendicular carcinoid tumor 3 (0.3%), oxyuriasis 2 (0.2%), and mycobacterial infection 4 (0.5%) were recognizable during the surgery. Of all pathologically confirmed cases with perforated appendicitis, 9.7% were not detected during the surgery.

Conclusion

In current study, acute appendicitis was the most common pathological diagnosis, however, high normal appendectomy rate along with noticeable proportion of surgically missed perforated appendicitis and unusual histopathologies strongly supported routine histological examination.     

Primary omental torsion in children: ten-year experience

Primary omental torsion (POT), is a rare cause of acute abdomen commonly affecting obese male adults, whereas it is extremely rare in children. In this retrospective study, we present our experience regarding the management of five children with POT and discuss the diagnostic and therapeutic implications of this entity. We retrospectively reviewed the medical records of children diagnosed for POT, from January 1996 to July 2006 at our department. Among 2,734 children operated for acute appendicitis, five patients were diagnosed with POT (ratio 1:587 or 0.18%). Clinical presentation, laboratory findings, diagnostic imaging results as well as surgical and histological findings were reviewed. There were four boys and one girl, M/F ratio 4:1, with a mean age of 9.5 years (range 7.2-10.3). All subjects were obese and their weight percentages were over 85% for their age group. On admission the clinical symptoms and laboratory findings were similar to those of acute appendicitis. They were submitted to laparotomy and the surgical findings were; free serosanguineous fluid in the peritoneal cavity, normal appendix and an ischemic twisted mass of the omentum at the right side of the abdomen. The mass and the appendix were excised and the postoperative course was uneventful. The histological examination of the specimens revealed hemorrhagic ischemic necrosis of the omentum and normal appendix. POT is very rare in children. In the pediatric age group the clinical presentation and the laboratory findings are similar to those of acute appendicitis and it is extremely difficult to be diagnosed preoperatively. Obesity seems to be an important predisposing high-risk factor. Excision of the twisted omentum is the treatment of choice.     

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。     

Hospital observation for right lower quadrant abdominal pain with questionable acute appendicitis in children

920 children below the age of 12 years were admitted with complaints of pain in the right lower abdomen and a suspected diagnosis of acute appendicitis. In 720 patients, clinical diagnosis was made and immediate operation was performed. In 644 of them (89.5%) an intraabdominal lesion was found but in 76 (10.5%) no disease was encountered. Rest 200 patients were observed in the ward and progression was noted at regular intervals. Eight of these patients did not improve while on observation and they were operated. Five others did not have acute appendicitis but in them definite medical diagnosis was made. However in remaining 187 observed patients abdominal signs gradually resolved and needed no surgery but no definite diagnosis also could be made. They appeared to have non-specific abdominal pain. The conclusion of the study was that inhospital observation of patients with right lower quadrant abdominal pain and questionable appendicitis upto three days was a safe way to reduce the rate of negative appendicectomies and unnecessary surgical exploration.     

Appendicitis in the young child: a continuing diagnostic challenge

OBJECTIVE: The purpose of this review was to examine the presenting signs and symptoms of children 5 years of age or less who underwent operation for appendicitis. In addition, we sought to determine the rate of perforation of the appendix and the effect on outcome in this age group. METHODS: Medical records for the period September 1987 to September 1998 were reviewed for all children 5 years of age or less who underwent appendectomy for appendicitis. Data gathered included age at operation, gender, care sought prior to admission for appendectomy, duration of symptoms, signs and symptoms at the time of admission, and length of postoperative hospital stay. Symptoms of diarrhea, emesis, fever, pain, and anorexia were recorded. Physical signs of an abdominal mass, guarding, rebound tenderness, rigidity, and diffuse or focal tenderness were recorded. Diagnostic information included white blood cell count with differential, and radiographic imaging, if obtained. The presence or absence of perforation of the appendix, and abscess formation were based on the intraoperative impression of the operating surgeon. RESULTS: For the 11-year period, 120 patients 5 years of age or less required an operation for appendicitis and had a complete medical database. The mean age was 3.6 +/- 1.3 years; 53% were male. Patients underwent a separate medical evaluation prior to arriving at a definitive diagnosis in 44.2 % cases. The most common presenting symptom was abdominal pain (94%); the most common sign was abdominal tenderness (95.8%). Tenderness was generally diffuse if perforation had occurred (62%) or focal in the nonperforated group (61%). The duration of symptoms in patients with perforation was more than double that of the nonperforated patients (4.7 vs 2.1 days, respectively). The mean white blood cell count (WBC) was 18.3 +/- 7.4 cells/mm3, and did not differ significantly between the perforated and nonperforated groups. A left shift detected in the WBC differential was present in 91%. An abdominal radiograph was obtained in 87%, and demonstrated a fecalith in 18%. A preoperative ultrasound was obtained in 38%, a computed tomographic scan in 7%. At the time of surgery, 74% were found to have evidence of perforation. An abscess was found at the initial surgery in 47% of patients with appendiceal perforation, but in no patient in whom perforation had not occurred. The rate of perforation increased as the age of the patient decreased (100% perforation for age 1 (n = 10) to 69% for age 5, (n = 35). Perforation was associated with a longer hospital length of stay as compared to the nonperforated appendix (median 9 days vs. 3 days, respectively, P < 0.001). There were no deaths in this series. CONCLUSION: Appendiceal perforation continues to be a common occurrence in the young child and increases in frequency as the age of the patient decreases and the duration of symptoms lengthens. Perforation results in a significant increase in hospital length of stay and rate of abscess formation.     

原发性小肠淋巴瘤的外科诊断与处理

目的 探讨小肠淋巴瘤与外科急腹症之间的鉴别诊断,以便采取正确的处理方法及早诊断和治疗.方法 对我院2000-2011年外科收治的10例小肠淋巴瘤患儿进行回顾性分析.结果 10例患儿中8例入院时诊断为阑尾炎或阑尾脓肿,2例诊断为急性肠套叠,经过反复分析病史,结合影像学所见,实行开腹探查.术中快速冰冻病理检查,确诊为小肠淋...     

Emergency Management of Acute Abdomen in Children

Acute abdomen can be defined as a medical emergency in which there is sudden and severe pain in abdomen with accompanying signs and symptoms that focus on an abdominal involvement. It accounts for about 8 % of all children attending the emergency department. The goal of emergency management is to identify and treat any life-threatening medical or surgical disease condition and relief from pain. In mild cases often the cause is gastritis or gastroenteritis, colic, constipation, pharyngo-tonsilitis, viral syndromes or acute febrile illnesses. The common surgical causes are malrotation and Volvulus (in early infancy), intussusception, acute appendicitis, and typhoid and ischemic enteritis with perforation. Lower lobe pneumonia, diabetic ketoacidosis and acute porphyria should be considered in patients with moderate-severe pain with little localizing findings in abdomen. The approach to management in ED should include, in order of priority, a rapid cardiopulmonary assessment to ensure hemodynamic stability, focused history and examination, surgical consult and radiologic examination to exclude life threatening surgical conditions, pain relief and specific diagnosis. In a sick patient the initial steps include rapid IV access and normal saline 20 ml/kg (in the presence of shock/hypovolemia), adequate analgesia, nothing per oral/IV fluids, Ryle’s tube aspiration and surgical consultation. An ultrasound abdomen is the first investigation in almost all cases with moderate and severe pain with localizing abdominal findings. In patients with significant abdominal trauma or features of pancreatitis, a Contrast enhanced computerized tomography (CECT) abdomen will be a better initial modality. Continuous monitoring and repeated physical examinations should be done in all cases. Specific management varies according to the specific etiology.     

Advancements in the diagnosis of acute appendicitis in children and adolescents.

The aim of our study was to further improve the preoperative diagnosis of acute appendicitis in children and adolescents. All diagnostic parameters from the patients' medical history (duration and quality of abdominal pain, stool behaviour), the laboratory (leukocytes, C-reactive protein), the clinic (defense, tenderness on percussion, nausea, vomiting, dry tongue) and repeated ultrasound investigations (visualisation of the appendix, indirect signs of an inflammatory process in the appendix region) were documented prospectively and were re-assessed with regard to their diagnostic value. As an additional parameter, procalcitonin was determined. 1156 patients (593 male/563 female) with a mean age of 9.51 years (+/- 1.2 yrs) (max. 15 yrs/min. 2.3 yrs), referred to the department with acute abdominal pain, were examined. 233 (141 male/92 female; 20.1 %) of these patients with a mean age of 10.47 years (+/- 1.1 yr) had appendicitis. Based on the patients' medical history, laboratory findings, the initial clinical investigation and the initial ultrasound investigation, 173 patients (74.3 % of the later operated 233 children with appendicitis) were diagnosed with certainty. The diagnosis of 60 patients (25.7 %) of this group remained uncertain. These patients received a saline enema (Clysmol, Pharmacia & Upjohn Company) and were subjected to a second clinical and sonographic investigation after approximately four hours of parenteral fluid substitution (Ringer's lactate, Mayrhofer Pharmazeutika Company, 4 ml/kg/h). The other 923 patients (79.83 %) were discharged and were followed up as outpatients in the following days. Based on this stepwise procedure, the percentage of correctly diagnosed appendicitis could be increased to 97.4 %. The measurement of procalcitonin proved to be of no value in the diagnosis of acute appendicitis. It may be concluded that in children with abdominal pain, high diagnostic accuracy can only be achieved by a carefully combined evaluation of all individual diagnostic parameters and repeated investigations.     

The impact of diagnostic delay on the course of acute appendicitis.

BACKGROUND: The diagnosis of acute appendicitis is often delayed, which may complicate the further course of the disease. AIMS: To review appendectomy cases in order to determine the incidence of diagnostic delay, the underlying factors, and impact on the course of the disease. METHODS: Records of all children who underwent appendectomy from 1994 to 1997 were reviewed. The 129 cases were divided into group A (diagnostic period within 48 hours) and group B (diagnostic period 48 hours or more). RESULTS: In the group with diagnostic delay, significantly more children had first been referred to a paediatrician rather than to a surgeon. In almost half of the cases in this group initial diagnosis was not appendicitis but gastroenteritis. The perforation rate in group A was 24%, and in group B, 71%. Children under 5 years of age all presented in the delayed group B and had a perforation rate of 82%. The delayed group showed a higher number of postoperative complications and a longer hospitalisation period. CONCLUSIONS: Appendicitis is hard to diagnose when, because of a progressing disease process, the classical clinical picture is absent. The major factor in diagnostic delay is suspected gastroenteritis. Early surgical consultation in a child with deteriorating gastroenteritis is advised. Ultrasonographs can be of major help if abdominal signs and symptoms are non-specific for appendicitis.     

The management of acute abdominal pain in children

Objective : Acute abdominal pain is a common problem in childhood, and appendicitis is frequently diagnosed by general practitioners and doctors working in emergency departments. The objective of the present report was to determine the frequency of appendicitis in a group of children with acute abdominal pain presenting to the emergency department of a general hospital, as well as attempting to analyse the manner in which these patients were managed.
Methodology : The initial assessment in hospital (by resident hospital staff) of the study group of patients was analysed and their subsequent clinical progress documented.
Results : The present report shows that the vast majority of children with acute abdominal pain do not have appendicitis and that appendicitis is significantly over-diagnosed by junior hospital doctors.
Conclusions : Appendicitis is a clinical diagnosis, best made by an experienced member of the paediatric surgical team. Frequent review, with a minimum of investigations, provides the best means of making a rational decision regarding surgery.     

Improving the diagnosis of acute appendicitis in children with atypical clinical findings using the technetium-99m hexamethylpropylene amine oxime-labelled white-blood-cell abdomen scan

BACKGROUND: Diagnosing acute appendicitis in children with equivocal signs and symptoms may be difficult. The usual approach is hospital observation and frequent re-examination. However, many surgeons are reluctant to delay surgery because of the risk of perforation and a negative laparotomy. OBJECTIVE: To assess and compare the value of the technetium-99m hexamethylpropylene amine oxime ((99m)Tc-HMPAO)-labelled white-blood-cell (WBC) abdomen scan in the diagnosis of acute appendicitis in children with atypical clinical presentation. PATIENTS AND METHODS: Fifty children with acute right lower quadrant abdominal pain and possible acute appendicitis, but atypical findings were included. After IV injection of (99m)Tc-HMPAO-labelled WBCs, serial anterior abdomen scans were obtained using a gamma camera. RESULTS: Thirty-three children underwent surgery, while 17 children were managed conservatively and were followed up for at least 1 month. Four children had false-positive results and one child had a false-negative scan result. The overall sensitivity, specificity, accuracy, positive predictive value and negative predictive value of the scan to diagnose acute appendicitis in children with atypical findings was 96.7, 80.0, 90.0, 87.8 and 94.1%, respectively. CONCLUSIONS: The (99m)Tc-HMPAO WBC abdomen scan is a potential tool for diagnosing acute appendicitis in children with atypical clinical findings. The high sensitivity and negative predictive value allows early discharge from the emergency department to avoid costly observation in hospital and potentially unnecessary surgery in those patients with negative scans.     

CT can reduce hospitalization for observation in children with suspected appendicitis

Background: There are no clinical or laboratory tests that can eliminate the possibility of appendicitis in a child with abdominal pain that suggests the diagnosis. The standard of care is to admit these children to the hospital for observation. More than twice as many children hospitalized for abdominal pain suggesting appendicitis are subsequently sent home after observation compared to those who undergo appendectomy. Objective: To evaluate the ability of CT with rectal contrast medium (CTRC) to diagnose a normal appendix in children with abdominal pain. Materials and methods: A prospective cohort study in an urban pediatric emergency department. Children 6–17 years of age with abdominal pain were eligible when the attending physician planned to admit them for observation for possible appendicitis. All 94 patients underwent CTRC. CTRC results were compared to patient outcomes. Results: Ninety-four children successfully underwent CTRC. Among the 53 patients with reflux of contrast medium into the ileum, the appendix was visualized in 43 (81.1%). Among all 94 cases, the appendix was visualized in 53 cases (55.7%); 43 studies were read as normal, and 10 showed appendicitis. Of the 43 with a normal appendix, 23 were discharged home, 18 were admitted but discharged uneventfully, and two underwent surgery for another diagnosis. When the appendix was visualized, the sensitivity, specificity, and negative and positive predictive values of CTRC were 100% (95% CI 66.4, 100.0), 97.7% (95% CI 88.0, 99.9), 100% (95% CI 91.8, 100.0), and 90% (95% CI 55.5, 99.8), respectively. The use of CTRC could have decreased the admission rate for observation for appendicitis by at least 41.8% and by more than 80% when the appendix could be seen. Conclusion: Our data suggest that when the appendix can be visualized, CTRC can accurately identify a normal appendix and reduce the number of children hospitalized for observation for possible appendicitis.Presented in part at the Pediatric Academic Societies annual meeting, Baltimore, Maryland, USA, May 2001     

Prospective evaluation of admission for acute abdominal pain in children

Acute abdominal pain (AAP) is one of the most frequent causes of admission to an emergency department of a childrens' hospital. The diagnosis viewed with the most apprehension is acute appendicitis. We present the results of a prospective study on the evaluation of the clinical and paraclinical symptoms generally observed in an AAP, and discuss the benefit of a diagnostic score for acute appendicitis. Twenty-five different diagnoses were observed, the 5 most frequent being: "non specific" (34.2%), constipation (16%), otorhinolaryngological infection (11.6%), gastroenteritis (10.7%) and acute appendicitis (10.5%). The study of 12 symptoms showed an elevated sensitivity for each one (92-50%), but a low positive predictive value (72-12%). Rigid adhesion to a diagnostic score would have led to unnecessary medical examination.