Gendel I, Gutermacher M, Buklan G, Lazar L, Kidron D, Paran H, Erez I
Meir Medical Center, Pediatrics, Kfar Saba, Israel.
Eur J Pediatr Surg. 2011 Aug;21(4):229-33. doi: 10.1055/s-0031-1273702. Epub 2011 Apr 8.
Aim of the study was to evaluate the relative value of the tools used to diagnose suspected acute appendicitis (AA) in children.
A retrospective review of data from 1 848 children admitted to the Pediatric Surgery Department between 2004 and 2008 in our university-affiliated medical center was conducted. A total of 780 children underwent appendectomy at first presentation. Of these patients, 75 children required removal of their appendix during laparotomy for other reasons and 19 had appendectomy following peri-appendicular abscess and were excluded from the study. The study included 686 children (2-16 years of age) with presumed AA managed by appendectomy. Clinical, laboratory, and imaging data were collected and compared to pathology results.
Of the 686 children who underwent surgery for suspected AA, 34 (5%) had a normal appendix (negative appendectomy rate). No statistical differences were found between normal and AA groups with regard to vomiting, diarrhea, pain duration, and peritoneal signs on admission. Children in the AA group were younger (10.9±3.2 vs. 12.1±2.3 years, p=0.004), had higher fever (36.9±0.7°C vs. 37.4±0.8°C, p=0.004), WBC (14.8±4.8 vs. 10.5±4.6×103/mL, p<0.0005), and neutrophil counts (77.2±11.1% vs. 64.0±15.9%, p<0.0005) on admission, and larger appendicular diameters on ultrasound (US) examination (0.9±0.2 cm vs. 0.7±0.08 cm, p<0.0005). The parameters with the highest positive predictive values for AA were WBC (>10×10 (3)/mL), neutrophil (>66%) count on admission (positive predictive value [PPV]=0.971 and 0.975, respectively), and appendicular diameter on US (>6 mm; PPV=0.968). These 3 parameters combined had a PPV of 0.991.
The results of laboratory tests (WBC, neutrophils) and imaging (US) contributed far more than clinical signs and symptoms (pain duration, vomiting, diarrhea, fever, and peritoneal signs at first physical examination) to the correct diagnosis of AA in children. When these 3 parameters were positive, the probability of a false positive (normal appendix) was only 1%. The contribution of US was particularly high as it was used primarily in patients in whom the diagnosis was in doubt and its results matched the final diagnosis better than diagnoses based on clinical signs and symptoms alone. It provides the additional benefit of no radiation exposure.
本研究旨在评估用于诊断儿童疑似急性阑尾炎（AA）的工具的相对价值。
对2004年至2008年在我校附属医院儿科手术科室收治的1848例儿童的数据进行回顾性分析。共有780例儿童在首次就诊时接受了阑尾切除术。其中，75例患者因其他原因在剖腹手术中需要切除阑尾，19例患者在阑尾周围脓肿形成后接受了阑尾切除术，这些患者被排除在研究之外。本研究纳入了686例（2至16岁）疑似AA且接受阑尾切除术治疗的儿童。收集临床、实验室和影像学数据，并与病理结果进行比较。
在686例因疑似AA接受手术的儿童中，34例（5%）阑尾正常（阴性阑尾切除率）。正常组和AA组在呕吐、腹泻、疼痛持续时间和入院时的腹膜征方面未发现统计学差异。AA组儿童年龄更小（10.9±3.2岁 vs. 12.1±2.3岁，p = 0.004），入院时发热更高（36.9±0.7°C vs. 37.4±0.8°C，p = 0.004），白细胞计数更高（14.8±4.8 vs. 10.5±4.6×10³/mL，p < 0.0005），中性粒细胞计数更高（77.2±11.1% vs. 64.0±15.9%，p < 0.0005），超声（US）检查时阑尾直径更大（0.9±0.2 cm vs. 0.7±0.08 cm，p < 0.0005）。对AA具有最高阳性预测值的参数是白细胞（>10×10³/mL）、入院时中性粒细胞计数（>66%）（阳性预测值[PPV]分别为0.971和0.975）以及US检查时阑尾直径（>6 mm；PPV = 0.968）。这三个参数联合使用时PPV为0.991。
实验室检查（白细胞、中性粒细胞）和影像学检查（US）对儿童AA的正确诊断的贡献远大于临床体征和症状（疼痛持续时间、呕吐、腹泻、发热以及首次体格检查时的腹膜征）。当这三个参数为阳性时，假阳性（阑尾正常）的概率仅为1%。US的贡献尤为突出，因为它主要用于诊断存疑的患者，其结果比仅基于临床体征和症状的诊断更符合最终诊断。它还具有无辐射暴露的额外益处。
