Diagnosing Ruptured Appendicitis Preoperatively in Pediatric Patients - 23/08/11

Doi : 10.1016/j.jamcollsurg.2009.01.029

Regan F. Williams, MD ^a,^b, Martin L. Blakely, MD, MS, FACS ^a,^b,^⁎, Peter E. Fischer, MD, MS ^a,^b, Christian J. Streck, MD ^c, Melvin S. Dassinger, MD ^d, Himesh Gupta, MD ^a,^b, Elizabeth J. Renaud, MD ^a,^b, James W. Eubanks, MD, FACS ^a,^b, Eunice Y. Huang, MD ^a,^b, S. Douglas Hixson, MD, FACS ^a,^b, Max R. Langham, MD, FACS ^a,^b
^a Division of Pediatric Surgery, University of Tennessee Health Science Center, Memphis, TN
^b LeBonheur Children's Medical Center, Memphis, TN
^c Division of Pediatric Surgery, Medical University of South Carolina, Charleston, SC
^d Division of Pediatric Surgery, University of Arkansas for Medical Sciences, Little Rock, AR

Correspondence address: Martin L Blakely, MD, University of Tennessee Health Science Center, 777 Washington Ave, Ste P220, Memphis, TN 38111

Résumé

Background

Over the past decade, pediatric patients with ruptured appendicitis (RA) have been successfully treated with IV antibiotics and an interval appendectomy. Because the treatment of acute appendicitis (AA) and RA in children is now diverging, distinguishing between these two conditions preoperatively is critical.

Study Design

A prospective cohort study was conducted. Clinical data were collected, and the attending surgeon's preoperative diagnosis was recorded. Accuracy of the pediatric surgeon's diagnosis was determined. Univariable and multivariable logistic regression were then used to determine independent clinical predictors of RA. Using the relative beta coefficients of these predictors, a scoring system was constructed to aid in the diagnosis of RA.

Results

Two hundred forty-seven patients were evaluated: 98 AA (40%), 53 RA (21%), and 97 not appendicitis (39%). Median age was 10 years old. The overall accuracy of the pediatric surgeon's preoperative diagnosis was 92%. Sensitivity and specificity for the diagnosis of RA were 96% and 83%, respectively. Multivariable regression analysis identified generalized tenderness on examination, duration of symptoms longer than 48 hours, WBC>19,400 cells/μL, abscess, and fecalith on CT scan as independent predictors for RA. A novel scoring system was developed with these variables, and, when applied to the study population, the specificity for the diagnosis of RA improved to 98%.

Conclusions

Pediatric surgeons differentiate AA from RA and not appendicitis preoperatively with high accuracy and sensitivity, but the specificity for diagnosing ruptured appendicitis is lower. The scoring system improved the specificity of the preoperative diagnosis. The validity and utility of this scoring system should be examined in future studies in larger patient populations.

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Abbreviations and Acronyms : AA, LR, NA, RA