Appendicitis risk prediction models in children presenting with right iliac fossa pain (RIFT study): a prospective, multicentre validation study

BACKGROUND: Acute appendicitis is the most common surgical emergency in children. Differentiation of acute appendicitis from conditions that do not require operative management can be challenging in children. This study aimed to identify the optimum risk prediction model to stratify acute appendicitis risk in children. METHODS: We did a rapid review to identify acute appendicitis risk prediction models. A prospective, multicentre cohort study was then done to evaluate performance of these models. Children (aged 5-15 years) presenting with acute right iliac fossa pain in the UK and Ireland were included. For each model, score cutoff thresholds were systematically varied to identify the best achievable specificity while maintaining a failure rate (ie, proportion of patients identified as low risk who had acute appendicitis) less than 5%. The normal appendicectomy rate was the proportion of resected appendixes found to be normal on histopathological examination. FINDINGS: 15 risk prediction models were identified that could be assessed. The cohort study enrolled 1827 children from 139 centres, of whom 630 (34·5%) underwent appendicectomy. The normal appendicectomy rate was 15·9% (100 of 630 patients). The Shera score was the best performing model, with an area under the curve of 0·84 (95% CI 0·82-0·86). Applying score cutoffs of 3 points or lower for children aged 5-10 years and girls aged 11-15 years, and 2 points or lower for boys aged 11-15 years, the failure rate was 3·3% (95% CI 2·0-5·2; 18 of 539 patients), specificity was 44·3% (95% CI 41·4-47·2; 521 of 1176), and positive predictive value was 41·4% (38·5-44·4; 463 of 1118). Positive predictive value for the Shera score with a cutoff of 6 points or lower (72·6%, 67·4-77·4) was similar to that of ultrasound scan (75·0%, 65·3-83·1). INTERPRETATION: The Shera score has the potential to identify a large group of children at low risk of acute appendicitis who could be considered for early discharge. Risk scoring does not identify children who should proceed directly to surgery. Medium-risk and high-risk children should undergo routine preoperative ultrasound imaging by operators trained to assess for acute appendicitis, and MRI or low-dose CT if uncertainty remains. FUNDING: None

The Alvarado score for predicting acute appendicitis: a systematic review

Background: The Alvarado score can be used to stratify patients with symptoms of suspected appendicitis; the validity of the score in certain patient groups and at different cut points is still unclear. The aim of this study was to assess the discrimination (diagnostic accuracy) and calibration performance of the Alvarado score. Methods: A systematic search of validation studies in Medline, Embase, DARE and The Cochrane library was performed up to April 2011. We assessed the diagnostic accuracy of the score at the two cut-off points: score of 5 (1 to 4 vs. 5 to 10) and score of 7 (1 to 6 vs. 7 to 10). Calibration was analysed across low (1 to 4), intermediate (5 to 6) and high (7 to 10) risk strata. The analysis focused on three sub-groups: men, women and children. Results: Forty-two studies were included in the review. In terms of diagnostic accuracy, the cut-point of 5 was good at 'ruling out' admission for appendicitis (sensitivity 99% overall, 96% men, 99% woman, 99% children). At the cut-point of 7, recommended for 'ruling in' appendicitis and progression to surgery, the score performed poorly in each subgroup (specificity overall 81%, men 57%, woman 73%, children 76%). The Alvarado score is well calibrated in men across all risk strata (low RR 1.06, 95% CI 0.87 to 1.28; intermediate 1.09, 0.86 to 1.37 and high 1.02, 0.97 to 1.08). The score over-predicts the probability of appendicitis in children in the intermediate and high risk groups and in women across all risk strata. Conclusions: The Alvarado score is a useful diagnostic 'rule out' score at a cut point of 5 for all patient groups. The score is well calibrated in men, inconsistent in children and over-predicts the probability of appendicitis in women across all strata of risk

Doubts, Problems and Certainties about Acute Appendicitis

Acute appendicitis is a common pediatric abdominal emergency, although it can occur in any age group. The debated role of imaging in diagnosis and diagnostic delays make diagnosis particularly challenging in the elderly. Given the heterogeneity of the population that may be affected by this disease, it is not possible to stipulate a universally valid diagnostic process. As such, an individualized approach guided by age, sex, comorbidities, and clinical manifestations is always necessary. This book reviews the current state of the art in acute appendicitis to help surgeons administer proper and timely treatment

Wses Jerusalem Guidelines For Diagnosis And Treatment Of Acute Appendicitis

Acute appendicitis (AA) is among the most common cause of acute abdominal pain. Diagnosis of AA is challenging; a variable combination of clinical signs and symptoms has been used together with laboratory findings in several scoring systems proposed for suggesting the probability of AA and the possible subsequent management pathway. The role of imaging in the diagnosis of AA is still debated, with variable use of US, CT and MRI in different settings worldwide. Up to date, comprehensive clinical guidelines for diagnosis and management of AA have never been issued. In July 2015, during the 3rd World Congress of the WSES, held in Jerusalem (Israel), a panel of experts including an Organizational Committee and Scientific Committee and Scientific Secretariat, participated to a Consensus Conference where eight panelists presented a number of statements developed for each of the eight main questions about diagnosis and management of AA. The statements were then voted, eventually modified and finally approved by the participants to The Consensus Conference and lately by the board of co-authors. The current paper is reporting the definitive Guidelines Statements on each of the following topics: 1) Diagnostic efficiency of clinical scoring systems, 2) Role of Imaging, 3) Non-operative treatment for uncomplicated appendicitis, 4) Timing of appendectomy and in-hospital delay, 5) Surgical treatment 6) Scoring systems for intra-operative grading of appendicitis and their clinical usefulness 7) Non-surgical treatment for complicated appendicitis: abscess or phlegmon 8) Pre-operative and post-operative antibiotics.1

Wses Jerusalem Guidelines For Diagnosis And Treatment Of Acute Appendicitis

Acute appendicitis (AA) is among the most common cause of acute abdominal pain. Diagnosis of AA is challenging; a variable combination of clinical signs and symptoms has been used together with laboratory findings in several scoring systems proposed for suggesting the probability of AA and the possible subsequent management pathway. The role of imaging in the diagnosis of AA is still debated, with variable use of US, CT and MRI in different settings worldwide. Up to date, comprehensive clinical guidelines for diagnosis and management of AA have never been issued. In July 2015, during the 3rd World Congress of the WSES, held in Jerusalem (Israel), a panel of experts including an Organizational Committee and Scientific Committee and Scientific Secretariat, participated to a Consensus Conference where eight panelists presented a number of statements developed for each of the eight main questions about diagnosis and management of AA. The statements were then voted, eventually modified and finally approved by the participants to The Consensus Conference and lately by the board of co-authors. The current paper is reporting the definitive Guidelines Statements on each of the following topics: 1) Diagnostic efficiency of clinical scoring systems, 2) Role of Imaging, 3) Non-operative treatment for uncomplicated appendicitis, 4) Timing of appendectomy and in-hospital delay, 5) Surgical treatment 6) Scoring systems for intra-operative grading of appendicitis and their clinical usefulness 7) Non-surgical treatment for complicated appendicitis: abscess or phlegmon 8) Pre-operative and post-operative antibiotics.1

Prospective validation of the APPEND clinical prediction rule within a pathway dedicated to right iliac fossa pain

Background Right iliac fossa (RIF) pain is one of the most common reasons for acute presentation to general surgical services, and acute appendicitis is one of the most common underlying diagnoses. The clinical diagnosis of appendicitis continues to challenge clinicians and this is reflected in negative appendicectomy rates of up to 20%. Clinical predication rules (CPRs) are one method used to improve diagnostic accuracy of diagnose appendicitis and reduce negative appendicectomy rates. The APPEND score is a novel CPR that was developed at Middlemore Hospital. Aim The aims of this thesis were firstly to undertake a systematic literature review of published CPRs, and secondly to prospectively evaluate the performance of the APPEND CPR within a pathway dedicated to the management of RIF pain. Methods A systematic review of the published CPRs for the diagnosis of appendicitis in adults was undertaken. All studies that derived or validated a CPR were included and their performance was assessed using sensitivity, specificity and area under curve (AUC) values. The second part of the thesis was a comparative cohort study of the APPEND CPR within a clinical pathway dedicated to managing adults presenting with RIF pain. The primary endpoint was negative appendicectomy rate and the study was powered to detect a 7% difference. Secondary outcomes were length of hospital stay and number of radiological investigations (ultrasound and CT) performed. Staff satisfaction with the APPEND CPR was assessed by a survey. Results Thirty-four papers fulfilled inclusion criteria for the systematic review; 12 derived a CPR and 22 validated these CPRs. Analysis was limited by the heterogeneity and quality of included studies. The overall best performer in terms of sensitivity (92%), specificity (63%), and AUC values (0.84 -0.97) was the Acute Inflammatory Response (AIR) score but only three studies validated this CPR. Prospective evaluation of the APPEND CPR was performed on 437 consecutive adult patients presenting acutely with RIF pain to Middlemore Hospital over a 6-month period. The negative appendicectomy rate in the prospective cohort was 9.2% (95% CI: 5.3%, 13.2%) compared to 19.8% (CI 16.2, 23.4%) in the retrospective cohort that did not use the APPEND CPR. After adjusting for multiple variables, the odds of a negative appendicectomy was 2.33 (95% CI; 1.26, 4.3, P value 0.007) in the retrospective cohort. An APPEND score of ≥ 5 was 87 % specific for ruling in appendicitis (PPV 94%) and a score of ≥ 1 was 100% sensitive in ruling out appendicitis (NPV 100%). There were more US scans but no significant difference in CT scans performed in the APPEND cohort. The length of stay was 0.9 days more in the APPEND cohort (p=< 0.0001). Survey respondents reported the APPEND CPR easy to use, but response rate was only 12%. Conclusion Twelve CPRs for the diagnosis of appendicitis in adults have been published. The AIR score appeared to perform best but further validation is required. In a comparative cohort study incorporating the APPEND CPR the rate of negative appendicectomy was reduced by more than 50%. Further validation of the APPEND CPR, including a comparison with the AIR, would be beneficial

Alvarado’s Criteria for Diagnosis of Children’s Acute Apendicitis

Acute abdomen in children is a condition that causes great distress to parents, and appendicitis is its most common cause, being more frequent at school age. This pathology is the cause of numerous visits to public and private hospitals around the world, and brings several complications. It is important that the health team is aware of the possibility of appendicitis in children, due to its high incidence and difficulty in establishing its diagnosis, because the symptoms are nonspecific and there are different clinical presentations. Objective: to explain the importance of the Alvarado criterion for the diagnosis of acute childhood appendicitis. Methodology: This is an integrative bibliographic review, in articles published in the PubMed, Virtual Health Library and Google Scholar databases. For the search for data, the descriptors “Acute abdomen”, “Appendicitis”, “Children” and the keyword “Alvarado score” were used. Data were collected in December 2020. Results: 16 articles were selected as the final sample for analysis of the review, six in English, nine in Portuguese and one in Spanish. Conclusion: Through this review it can be concluded that the use of the Alvarado Score for the diagnosis of acute appendicitis in children is useful and effective, avoiding the use of imaging tests in patients with a score above 7 on this scale

Terminal ileum herniation through the broad ligament as rare cause of small bowel perforation

INTRODUCTION: Obstruction and perforation of small bowel due to internal herniation into the broad ligament is a rare. To the best of our knowledge, this is the third case report in the literature. OBJECTIVE: We report a case of small bowel herniated through broad ligament causing obstruction and perforation. REPORT A 38-year-old female with history of recent lower segment caesarean section, presented with nausea, abdominal pain and distention for 11 days prior. Clinically she was dehydrated, the abdomen was distended and tender but there was no peritonism. Abdomen X-ray show dilated small bowel. Contrast enhanced CT abdomen showed generalized dilation of small bowel most likely due to adhesion band. Emergency laparotomy was performed and noted small bowel was herniated and strangulated into a broad ligament defect with 2cm perforation at the terminal ileum. The attachment of the broad ligament then was released from the lateral peritoneal wall and limited right hemicolectomy with primary anastomosis was performed. Patient was discharged well post operatively. CONCLUSION Strangulated Small bowel broad ligament hernias are rare and challenging to diagnose preoperatively. Despite history of abdominal surgery, internal herniation should be considered before opting conservative treatment

Diagnostic accuracy of blood tests of inflammation in paediatric appendicitis: a systematic review and meta-analysis

Objective: Possible childhood appendicitis is a common emergency presentation. The exact value of blood tests is debated. This study sought to determine the diagnostic accuracy of four blood tests (white cell count (WCC), neutrophil(count or percentage), C reactive protein (CRP) and/or procalcitonin) for childhood appendicitis. Design: A systematic review and diagnostic meta-analysis. Data sources included MEDLINE, EMBASE, Central, Web of Science searched from inception-March 2022 with reference searching and authors contacted for missing/unclear data. Eligibility criteria was studies reporting the diagnostic accuracy of the four blood tests compared to the reference standard (histology or follow-up). Risk of bias was assessed (QUADAS-2), pooled sensitivity and specificity were generated for each test and commonly presented cut-offs. To provide insight into clinical impact, we present strategies using a hypothetical cohort. Results: 67 studies were included (34 839 children, 13 342 with appendicitis), all in the hospital setting. The most sensitive tests were WCC (≥10 000 cells/µL, 53 studies sensitivity 0.85 (95% CI 0.80 to 0.89)) and absolute neutrophil count (ANC) (≥7500 cells/µL, five studies sensitivity 0.90 (95% CI 0.85 to 0.94)). Combination of WCC or CRP increased sensitivity further(≥10 000 cells/µL or ≥10 mg/L, individual patient data (IPD) of 6 studies, 0.97 (95% CI 0.93 to 0.99)). Applying results to a hypothetical cohort(1000 children with appendicitis symptoms, of whom 400 have appendicitis) 60 and 40 children would be wrongly discharged based solely on WCC and ANC, respectively, 12 with combination of WCC or CRP. The most specific tests were CRP alone (≥50 mg/L, 38 studies, specificity 0.87 (95% CI 0.80 to 0.91)) or combined with WCC (≥10 000 cells/µL and ≥50 mg/L, IPD of six studies, 0.93 (95% CI 0.91 to 0.95)). Conclusions: The best performing single blood tests for ruling-out paediatric appendicitis are WCC or ANC; with accuracy improved combining WCC and CRP. These tests could be used at the point of care in combination with clinical prediction rules. We provide insight into the best cut-offs for clinical application. PROSPERO registration number: CRD4201708003

Obstructed pedunculated jejunal gastrointestinal Stromal tumor disguise as pelvic mass - a case report

INTRODUCTION: Obstructed pedunculated jejunal gastrointestinal stromal tumours (GISTs) are very rare and can be misdiagnosed as gynaecological masses. OBJECTIVE: We are describing a rare case of small bowel obstruction caused by a jejunal GIST misdiagnosed as an ovarian mass. CASE REPORT A 70-year-old lady presented with abdominal pain, vomiting, and no bowel movement for three days prior. Clinical abdominal examination reveals a palpable mass at the level of the umbilicus, which was unable to feel the lower border of it. Contrasted CT Abdomen revealed a solid cystic mass in the pelvis, suspected to be ovarian in origin and associated with small bowel dilatation. The patient was subjected to exploratory laparotomy, which revealed a 12x13cm pedunculated mass from the jejunum 115cm from the duodenojejunal junction. The lesion was twisted and caused small bowel dilatation. The lesion was resected at the base of the peduncle using a linear stapler. Pathology was confirmed to be a high-risk GIST with a clear margin. The patient's postoperative course was uneventful, and she was discharged on the third postoperative day. The patient is currently receiving adjuvant imatinib therapy. CONCLUSION: Obstructed pedunculated jejunal GIST is a very rare disease and challenging to diagnose. It should be considered in patients with small bowel obstruction and pelvic mass. Resection at the peduncle base is safe and provides a clear oncological resection margin