Diagnosis and Management of Pediatric Appendicitis, Intussusception, and Meckel Diverticulum

An incidental appendectomy is performed by some surgeons during operative treatment for intussusception to eliminate future appendicitis as a diagnostic consideration. However, an appendectomy can increase the risk of infection and other noninfectious complications making an incidental appendectomy controversial. We examined outcomes for surgical intervention for intussusception with appendectomy (SWA) compared to surgical reduction alone (SRA).

The Pediatric Health Information System database, 8/2008–9/2015, was retrospectively analyzed for patients under the age of five who required an operative intervention for intussusception without bowel resection. Demographic data and postoperative outcomes were analyzed. Available data included need for postoperative enema, subsequent small bowel obstruction, recurrent intussusception, length of stay (LOS), and adjusted total cost (ATC).

Fifty-seven percent (748/1312) of patients had appendectomy performed during surgical reduction, 564 (43%) did not. ATC ($10,594 vs. $8939, p < 0.001) and LOS (3.0 vs. 2.48, p < 0.001) are higher in the SWA group. Rates of readmission are similar, but post-operative small bowel obstruction may be higher in the SWA group (1.3% vs. 0.35%, p = 0.06).

There is a higher mean LOS and ATC in the SWA group. This study suggests that appendectomy during surgery for uncomplicated intussusception should be reconsidered and requires further investigation.

retrospective comparative study.

III.

In China, rotavirus is the leading cause of diarrhea hospitalizations among children aged <5 years. A locally manufactured rotavirus vaccine is available for private market use, but little is known about its coverage. Given the impending availability of newer rotavirus vaccines, we evaluated intussusception rates among children aged <2 years to better understand intussusception epidemiology for future vaccine safety monitoring.

We conducted a retrospective review at 4 hospitals in Chenzhou City of Hunan Province and Kaifeng City of Henan Province. We identified intussusception cases admitted during 2009–2013 by reviewing medical records with the ICD-10 discharge code for intussusception and extracting demographic and clinical information from the electronic clinical record systems.

During 2009–2013, 1715 intussusception hospitalizations among 1,487,215 children aged <2 years occurred in both cities. The average annual intussusception hospitalization incidence was 112.9 per 100,000 children aged <2 years (181.8 per 100,000 children <1 year; 56 per 100,000 children 1 to <2 years). Intussusception incidence was low among infants aged <3 months and peaked at age 6–8 months. No clear seasonality was observed. Ultrasound was used to diagnose 95.9% of cases. Enema reduction was performed in 80% cases; 25% of cases in Chenzhou and 16% in Kaifeng required surgical intervention. No deaths were reported. The median time between symptom onset and admission was 1 day.

This study provides information on intussusception incidence and epidemiology in two cities of China during 2009–2013. Monitoring intussusception rates in this population will be important in the post-rotavirus vaccine era.

Computed tomography should be performed after careful consideration due to radiation hazard, which is why interest in low dose CT has increased recently in acute appendicitis. Previous studies have been performed in adult and adolescents populations, but no studies have reported on the efficacy of using low-dose CT in children younger than 10 years.

Patients (n = 475) younger than 10 years who were examined for acute appendicitis were recruited. Subjects were divided into three groups according to the examinations performed: low-dose CT, ultrasonography, and standard-dose CT. Subjects were categorized according to age and body mass index (BMI).

Low-dose CT was a contributive tool in diagnosing appendicitis, and it was an adequate method, when compared with ultrasonography and standard-dose CT in terms of sensitivity (95.5% vs. 95.0% and 94.5%, p = 0.794), specificity (94.9% vs. 80.0% and 98.8%, p = 0.024), positive-predictive value (96.4% vs. 92.7% and 97.2%, p = 0.019), and negative-predictive value (93.7% vs. 85.7% and 91.3%, p = 0.890). Low-dose CT accurately diagnosed patients with a perforated appendix. Acute appendicitis was effectively diagnosed using low-dose CT in both early and middle childhood. BMI did not influence the accuracy of detecting acute appendicitis on low-dose CT.

Low-dose CT is effective and accurate for diagnosing acute appendicitis in childhood, as well as in adolescents and young adults. Additionally, low-dose CT was relatively accurate, irrespective of age or BMI, for detecting acute appendicitis. Therefore, low-dose CT is recommended for assessing children with suspected acute appendicitis.

A tomografia computadorizada deve ser realizada após cautelosa consideração devido ao perigo de radiação, motivo pelo qual o interesse na TC de baixa dosagem tem aumentado recentemente em casos de apendicite aguda. Estudos anteriores foram realizados em populações adultas ou adolescentes, porém nenhum estudo relatou a eficácia do uso da TC de baixa dosagem em crianças com menos de 10 anos de idade.

Recrutamos pacientes (n = 475) com menos de 10 anos de idade examinados com relação a apendicite aguda. Os indivíduos foram divididos em três grupos de acordo com os exames realizados: TC de baixa dosagem, ultrassonografia e TC de dosagem padrão. Os indivíduos foram categorizados de acordo com a idade e o índice de massa corporal.

A TC de baixa dosagem foi uma ferramenta de grande contribuição no diagnóstico de apendicite e um método adequado em comparação à ultrassonografia e à TC de dosagem padrão em termos de sensibilidade (95,5% em comparação a 95,0% e 94,5%, p = 0,794), especificidade (94,9% em comparação a 80,0% e 98,8%, p = 0,024), valor preditivo positivo (96,4% em comparação a 92,7% e 97,2%, p = 0,019) e valor preditivo negativo (93,7% em comparação a 85,7% e 91,3%, p = 0,890). A TC de baixa dosagem diagnosticou de forma precisa pacientes com um apêndice perfurado. A apendicite aguda foi diagnosticada de maneira efetiva utilizando a TC de baixa dosagem tanto na primeira quanto na segunda infância. O IMC não influenciou a precisão da detecção de apendicite aguda na TC de baixa dosagem.

A TC de baixa dosagem é eficaz e precisa no diagnóstico de apendicite aguda na infância, bem como em adolescentes e jovens adultos. Além disso, a TC de baixa dosagem foi relativamente precisa, independentemente de idade ou IMC, na detecção de apendicite aguda. Assim, a TC de baixa dosagem é recomendada na avaliação de crianças com suspeita de apendicite aguda.

In 2017, a provincial guideline was created to fast track and standardize care for pediatric appendicitis in Alberta. We conducted a study to determine the impact of implementation of the guideline at our institution on length of stay (LOS), antibiotic stewardship efforts and costs.

We performed a retrospective review of the charts of all patients younger than 18 years of age who underwent appendectomy at our institution in 2 periods: before guideline implementation (Dec. 1, 2016, to May 31, 2017) and after implementation (Dec. 1, 2017, to May 31, 2018). We compared LOS, duration of antibiotic therapy, 30-day postdischarge complication rates and variable cost between the 2 cohorts.

Of the 276 total appendectomy procedures performed, 185 were for simple appendicitis (81 before guideline implementation and 104 after implementation), and 91 were for complicated appendicitis (44 and 47, respectively). The median LOS was shorter in the postimplementation cohort for both simple and complicated appendicitis (15.5 h [interquartile range (IQR) 12–19 h] v. 17.0 h [IQR 13–22 h], p = 0.03; and 3.0 d [IQR 2–4 d] v. 3.0 d [IQR 3–5 d], p = 0.05, respectively). Patients with complicated appendicitis had fewer antibiotic days after guideline implementation; the difference was statistically significant for patients without diffuse peritoneal contamination or abscess formation (p = 0.02). There were no differences between the cohorts with respect to 30-day rates of complications, including emergency department visits, readmission and surgical site infections. After guideline implementation, the average variable cost per patient was reduced by $230, equating to a total average annual cost savings of $75 842 for our institution.

The implementation of a provincial guideline aimed at standardizing care in pediatric appendicitis at our institution was associated with shortened LOS, improved antibiotic stewardship efforts and reduced cost of care. Other institutions may replicate our model of a standardized pathway in the management of pediatric appendicitis in an effort to improve the quality of patient care and reduce health care costs.

En 2017, des lignes directrices provinciales ont vu le jour en Alberta afin d’accélérer et de normaliser les soins pédiatriques pour appendicite. Notre étude visait à déterminer l’effet de leur application, par notre établissement, sur la durée du séjour, la gestion des antibiotiques et les coûts des soins.

Nous avons examiné de façon rétrospective le dossier de tous les patients de moins de 18 ans ayant subi une appendicectomie à notre établissement avant l’application des lignes directrices (entre le 1^er décembre 2016 et le 31 mai 2017) et après (entre le 1^er décembre 2017 et le 31 mai 2018). Les données relatives à la durée du séjour, à la durée de l’antibiothérapie, au taux de complications 30 jours après le congé et aux coûts variables ont été comparées entre les 2 groupes.

Des 276 appendicectomies totales effectuées, 185 concernaient une appendicite simple (81 avant l’application des lignes directrices et 104 après), et 91, une appendicite compliquée (44 avant l’application et 47 après). La durée médiane du séjour était plus courte dans le groupe postapplication, tant pour l’appendicite simple (15,5 h [écart interquartile (EI) 12–19 h] c. 17,0 h [EI 13–22 h]; p = 0,03) que pour l’appendicite compliquée (3,0 j [EI 2–4 j] c. 3,0 j [EI 3–5 j]; p = 0,05). Les patients qui présentaient une appendicite compliquée avaient une antibiothérapie moins longue après l’application des lignes directrices; la différence était statistiquement significative chez les patients sans contamination péritonéale diffuse ou abcès (p = 0,02). Aucune différence n’a été observée entre les cohortes en ce qui a trait au taux de complications à 30 jours, qui comprenait les consultations à l’urgence, les réadmissions et les infections du site opératoire. L’application des lignes directrices a permis de réduire les coûts variables par patient de 230 $, ce qui représente une économie annuelle moyenne de 75 842 $ pour notre établissement.

L’application des lignes directrices provinciales visant à normaliser les soins pédiatriques pour appendicite a été associée, dans notre établissement, à une réduction de la durée du séjour, à l’amélioration de la gestion des antibiotiques et à une diminution des coûts des soins. D’autres établissements pourraient reproduire ce modèle de soins normalisés pour améliorer la qualité et réduire les coûts.