The clinical picture of acute appendicitis in children

The authors describe 3860 child patients operated on account of acute appendicitis and analyse the data with regard to age, sex, year of incidence and surgical finding. The highest incidence of acute appendicitis is between 8 and 11 years with a peak at the age of 10 years. It is more frequent in boys (58.3%) than in girls (43.7%), the ratio being 1.3:1. It occurs more often during the cold months (46.5%), in autumn (27.3%) and in winter (25.7%). The number of gangrenous appendicitis is 34.7%-56.7% in boys and 43.5% in girls. The highest rate of missed appendicitis is at the age of the highest incidence (15.2%) with a peak at the age of 10 years (17.8%) and in January (13.3%). The highest incidence of perforated appendicitis is also at the age of the highest incidence (14.9%) with the peak at the age of 8 years (15.6%) and in June (13.5%). Perforation is more frequent in boys (58.1%) than in girls (49.9%). The number of "negative" appendicitis is 15.8%. Prevention of acute appendicitis still remains open due to lack of knowledge of its etiopathogenesis.     

Late complications after surgery of acute appendicitis in children

The causes of the late complications of appendicular peritonitis were analyzed in 48 patients (20 of them were previously operated on in the clinic, 28--in other hospitals). The principles of treatment, follow-up results, the complications prophylaxis are expounded.     

Laboratory aid and ultrasonography in the diagnosis of appendicitis in children

The purpose of this study was to evaluate the relationship between the number of yolk sacs and amnionicity in monochorionic twin pregnancies scanned early in the first trimester. We retrospectively reviewed images of all monochorionic twins scanned between 6 and 9.5 weeks' gestation and with pathologic or sonographic confirmation of chorionicity-amnionicity. Each film was reviewed for the number of yolk sacs present, as well as for the gestational age at which the amniotic membrane was first visualized. Twenty monochorionic-diamniotic pregnancies and two monochorionic-monoamniotic pregnancies met the criteria for inclusion in the study. In diamniotic pregnancies scanned at less than 8 weeks' gestation, only the yolk sacs were identified; none of the dividing amniotic membranes were detected. Two yolk sacs were identified in all but one case. In this case, although one yolk sac was seen at 6 weeks, follow-up scanning at 8 weeks revealed two yolk sacs. In each of the monochorionic-monoamniotic twin pregnancies, one yolk sac was seen at 9 weeks and a single amnion encircled both embryos. We conclude that the sonographic identification of two yolk scas in monochorionic twins enables us to make the diagnosis of diamniotic twins early in the first trimester, before the amniotic membrane can be imaged. The presence of one yolk sac should prompt a follow-up ultrasonogram to assign amnionicity definitively.     

婴幼儿急性阑尾炎的诊治体会

目的 探讨婴幼儿急性阑尾炎的诊断及治疗特点.方法收集我院自2003年11月～2009年12月期间共收治的49例婴幼儿急性阑尾炎的临床资料,总结分析临床特点及治疗经验.结果 49例均有发热、腹痛、中性粒细胞升高的主要临床表现,25例有腹胀、呕吐,15例有腹泻,9例有肠梗阻,49例均行手术治疗,经术中及病理证实诊断,术后均恢复良好.结论 婴幼儿急性阑尾炎因发作时缺乏典型的病史和腹部体征,常易误诊和延误治疗,发热、腹痛、中性粒细胞升高仍为其诊断的主要依据,婴幼儿急性阑尾炎一经诊断应尽早积极手术治疗,以避免严重并发症的发生.     

Comparative trial of four antibiotic combinations for perforated appendicitis in children

Breast cancer is in 5% of cases due to a genetic disposition. BRCA1 and BRCA2 are by far the most common breast cancer susceptibility genes. For a woman with a genetic predisposition, the individual risk of developing breast cancer sometime in her life is between 70 and 90%. Compared to the spontaneous forms of breast cancer, woman with a genetic predisposition often develop breast cancer at a much younger age. This is why conventional screening programs on the basis of mammography alone cannot be applied without modification to this high-risk group. In this article, an integrated screening concept for women with genetic predisposition for breast cancer using breast self-examination, clinical examination, ultrasound, mammography and magnetic resonance imaging is introduced.     

Should laparoscopic appendectomy be avoided for complicated appendicitis in children?

BACKGROUND/PURPOSE: Laparoscopic appendectomy is becoming the preferred technique for treating acute appendicitis. However, recent literature on adults suggests that laparoscopic appendectomy may increase the risk for postoperative infectious complications in complicated (gangrenous or perforated) cases. This study was undertaken to compare the results of open versus laparoscopic appendectomy for complicated appendicitis in children. METHODS: A retrospective review from two institutions was performed for all children treated operatively for complicated appendicitis from January 1994 through November 1996. RESULTS: Fifty-six cases were identified. Twenty-seven children underwent laparoscopic appendectomy, whereas 22 underwent open appendectomy. Seven children underwent conversion from laparoscopic to open surgery. Operating times and length of hospital stay did not differ significantly between the laparoscopic and open groups. Postoperative complications developed in 24 children (42.8%). Complications were more frequent after laparoscopic appendectomy compared with open appendectomy (56% v 18%, P = .002). A postoperative intraabdominal abscess (IAA) developed in 14 children (25%). An IAA occurred in two children after open appendectomy compared with 11 children after laparoscopic appendectomy (9% v 41%, P = .01). CONCLUSION: The findings suggest that laparoscopic appendectomy should be avoided in children who have complicated appendicitis because of the increased risk for postoperative intraabdominal abscesses. The authors propose a prospective, randomized trial to verify this finding.     

Appendiceal CT in 140 cases. Diagnostic criteria for acute and necrotizing appendicitis

Computed tomography (CT) was performed in 140 patients with suspected acute appendicitis. Thin collimation (5 mm), intravenous contrast enhancement, 1-second scan times, and supplementary cecal air insufflation were emphasized. CT accuracy was 98% overall (137/140), and 99% in the 124 cases with early surgery. Necrotizing appendicitis was diagnosed by CT with 86% accuracy and 90% positive predictive value.     

Perforated appendicitis in children: risk factors for the development of complications

BACKGROUND: Many aspects of the management of perforated appendicitis in children remain controversial. The objective of this study was to define risk factors associated with the development of postoperative complications in children undergoing treatment for perforated appendicitis. METHODS: We reviewed all children (age < 16 years) who were treated for perforated appendicitis at Cardinal Glennon Children's Hospital between 1988 and 1997. Inclusion criteria included either gross or microscopic evidence of appendiceal perforation. RESULTS: Of 285 children with perforated appendicitis, 279 underwent immediate operative treatment. Mean patient age was 7.7 years and there were no deaths. Major postoperative complications included intra-abdominal abscess (n = 17), ileus (n = 7), mechanical intestinal obstruction (n = 6), and wound infection (n = 4). All children who had a postoperative abscess had more than 5 days of symptoms before operation. Within this subgroup, drain placement was associated with not only decreased postoperative abscess formation and but also shorter duration of fever and length of hospitalization. The incidence of mechanical obstruction or ileus was not increased and the rate of wound infection was actually lower after drainage. CONCLUSIONS: Drain placement appears to be helpful in children with late diagnosis but is of little benefit when the duration of symptoms is less than 5 days. Thus it is likely that drains are most useful in patients with well-established and localized abscess cavities.     

CT appearance of pulmonary vasculitis in children

OBJECTIVE: The aim of this study was to determine whether a CT pattern that may represent early or subtle changes of pulmonary vasculitis in children exists. MATERIALS AND METHODS: High-resolution CT scans of the chest for 107 children were retrospectively reviewed by two radiologists who were unaware of the original study findings. Chest CT scans (conventional) for another 54 children who had symptoms or a diagnosis of vasculitis also were reviewed. RESULTS: We identified hazy or fluffy centrilobular, perivascular densities in 10 children, two of whom had small airways disease and eight of whom had vasculitis (Wegener's granulomatosis [n = 5], systemic lupus erythematosus [n = 1], scleroderma-polymyositis overlap syndrome [n = 1], and Churg-Strauss syndrome [n = 1]). The latter eight children underwent 35 scans, 17 of which were positive for these perivascular densities. All positive scans were associated with active disease of new onset (5/17) or with clinical exacerbation of preexisting systemic disease (12/17). The positive scans also were associated with an elevated erythrocyte sedimentation rate (13/17) and biopsy evidence of vasculitis from a variety of sites, including the lungs (n = 1), kidneys (n = 7), oropharynx (n = 5), skin (n = 9), lymph nodes (n = 1), and myocardium (n = 2). The single lung biopsy showed an angiocentric inflammatory-hemorrhagic process. Of the five patients who had positive scans, underwent therapy, and then had repeat studies, four patients had scans revert to normal in association with inactive disease. The remaining patient whose scan did not normalize failed to respond to treatment. CONCLUSION: The fluffy centrilobular pattern likely represents subtle changes of pulmonary vasculitis. In the appropriate clinical setting, such a finding may obviate the need for a lung biopsy.     

The activity of trypsin and proteolytic inhibitors in complicated forms of appendicitis in children

Adequate policy of price formation is one condition for effective development of public health under conditions of market economy. The authors present the fundamentals of price formation in public health under conditions of state financing, insurance, and self-support. Price formation should promote the activities of public health institutions, aimed at improving the quality of medical aid to the population and at the creation of conditions for the welfare of medical workers.     

Reoperations in appendicitis

We present our experience in reoperations after appendectomy. From 276 patients were operated for acute appendicitis, we found 70 who presented appendicular abscess, only 13 needed reoperation because of residual abscess, (three cases), evisceration (four cases), and cecum perforation (two cases). All had history of more than four days of preoperative evolution (range 4-45 days) in those eleven patients (six men, and five women) were done 13 reoperations. We had no mortality after successful recovery in all of theme. Our experience in reported from the surgical services of Hospital General de México an Hospital Juárez, both located in México City.     

Acute graft-versus-host disease in children: abdominal CT findings

PURPOSE: To review the computed tomographic (CT) appearance of acute gastrointestinal graft-versus-host disease (GVHD) in children. MATERIALS AND METHODS: Sixteen abdominal CT scans obtained in 12 children with acute gastrointestinal GVHD who underwent allogeneic bone marrow transplantation (BMT) were compared with 16 CT scans obtained in autologous bone marrow recipients not at risk for GVHD (control group). Autopsy findings in six patients with GVHD were compared with CT findings. RESULTS: All CT scans in patients with GVHD showed an abnormally enhanced, thin mucosal layer of bowel wall involving fluid-filled, dilated, poorly opacified bowel loops from the duodenum to the rectum. This corresponded histologically to mucosal destruction and replacement by a thin layer of highly vascular granulation tissue. Bowel wall thickening was often absent. Infiltration of mesenteric fat was seen in 91% of patients The control group showed no similar abnormalities. CONCLUSION: Acute gastrointestinal GVHD characteristically appears on CT scans as multiple, diffuse, fluid-filled bowel loops with a thin, enhancing layer of bowel wall mucosa. Bowel wall thickening often is absent.     

Foreign-body appendicitis

The authors report the case of a 9-year-old boy who had a needle in his appendix. The contrast between absence of clinical symptoms and clear inflammatory changes of the appendix is noted. The authors recommend appendectomy for patients with pointed foreign bodies in the appendix to avoid inflammation and perforation.     

Using unenhanced helical CT with enteric contrast material for suspected appendicitis in patients treated at a community hospital

OBJECTIVE: We evaluated the accuracy of unenhanced helical CT with enteric contrast material in the diagnosis of appendicitis in children and adults treated at a community hospital. SUBJECTS AND METHODS: Over an 8-month period, 100 consecutive patients with right lower quadrant pain and suspected appendicitis were prospectively evaluated. Thin-collimation helical CT scanning was performed after administration of enteric contrast material. CT interpretations were correlated with surgical pathology (45 patients) and clinical follow-up (55 patients). RESULTS: The findings of 33 CT scans were interpreted as positive for appendicitis (29 true-positives and four false-positives), and the findings of 67 were interpreted as negative for appendicitis (66 true-negatives and one false-negative). Sensitivity was 97%, specificity was 94%, accuracy was 95%, positive predictive value was 88%, and negative predictive value was 99%. In the 67 CT scans with negative findings for appendicitis, an alternative diagnosis was made for 36 patients (54%). CONCLUSION: Unenhanced helical CT with enteric contrast material for the evaluation of appendicitis can be implemented in a community hospital. In our study, such imaging achieved excellent accuracy.