INTRODUCTION: This study aimed to investigate the ultrasonographic features of paediatric acute appendicitis and incorporate them into a scoring algorithm that will quantify the risk of complications and the strength of recommendation for surgical intervention. METHODS: 179 patients with suspected appendicitis who had undergone ultrasonographic examination were included in this study. Based on their medical evaluation and post-surgical histopathological results, patients were categorised into confirmed appendicitis (n = 101) and non-appendicitis (n = 78) groups. RESULTS: In the appendicitis group, the appendix was visualised in 66 (65.3%) patients. In cases where the appendix was not visualised, we looked out for secondary inflammatory signs, which were present in 32 (31.7%) patients. Using stepwise logistic regression, Blumberg's sign, free fluid or collection, hyperaemia, non-compressible appendix and an appendix diameter > 7 mm were found to be significant predictive factors for appendicitis. A new scoring system called POPs was developed, combining inflammatory predictors and ultrasonography findings, with an area under the receiver operating characteristic curve of 0.958 (95% confidence interval 0.929-0.986). CONCLUSION The newly developed POPs-based diagnosis scheme proved a promising alternative to existing scoring systems such as the Alvarado score. Although further calibration would be beneficial, the proposed scoring scheme is simple and easy to understand, memorise and apply in the emergency room.
Acute Disease ; Appendectomy ; Appendicitis/surgery* ; Appendix/surgery* ; Child ; Humans ; Sensitivity and Specificity ; Ultrasonography/methods*

OBJECTIVES: To study the clinical efficacy of ultrasound-guided endoscopic retrograde appendicitis therapy in children with appendix-related chronic abdominal pain. METHODS: A retrospective analysis was performed on the medical data of 30 children with the chief complaint of chronic abdominal pain who were admitted from August 2019 to May 2021. All the children were found to have inflammation of the appendix or intracavitary stool and fecalith by ultrasound and underwent ultrasound-guided endoscopic retrograde appendicitis therapy. The medical data for analysis included clinical manifestations, endoscopic findings, white blood cell count, neutrophil percentage, length of hospital stay, and cure rate. RESULTS: Among the 30 children with chronic abdominal pain, there were 13 boys (43%) and 17 girls (57%), with a mean age of (9±3) years (range 3-15 years) at diagnosis. The median duration of the disease was 12 months, and the median length of hospital stay was 3 days. The children had a median white blood cell count of 6.7×10⁹/L and a neutrophil percentage of 50%±13%. Fecalith and a large amount of feces were flushed out of the appendix cavity for 21 children (70%) during surgery. The follow-up rate was 97% (29/30), and the median follow-up time was 11 months (range 5-26 months). Of the 29 children, abdominal pain completely disappeared in 27 children (93%). CONCLUSIONS Ultrasound-guided endoscopic retrograde appendicitis therapy is effective in children with chronic abdominal pain caused by feces or fecalith in the appendix cavity.
Abdominal Pain/etiology* ; Adolescent ; Appendicitis/surgery* ; Appendix/surgery* ; Child ; Child, Preschool ; Fecal Impaction ; Female ; Humans ; Male ; Retrospective Studies ; Ultrasonography, Interventional

PURPOSE: The purpose of this study was to determine whether the awareness and inclusion of secondary sonographic signs of appendicitis, in combination with a structured evaluation as part of engagement and training for sonographers, improved appendix visualization rates and reduced equivocal findings in children with suspected acute appendicitis. METHODS: This was a prospective study of 230 children at a tertiary children's hospital in Australia referred for an ultrasound examination of suspected appendicitis. The ultrasound findings, radiology reports, histology, clinical results, and follow-up were collated. Secondary signs were used as an additional assessment of the likelihood of disease where possible, even in the absence of an identified appendix. RESULTS: The implementation of a structured evaluation as part of sonographer engagement and training resulted in a 28% improvement in appendix visualization (68.7%) compared with a prior retrospective study in a similar population (40.7%). The diagnostic accuracy was 91.7%, with likelihood ratios suggesting a meaningful influence of the pre-test probability of appendicitis in children studied (positive likelihood ratio, 11.22; negative likelihood ratio, 0.09.). Only 7.8% of the findings were equivocal. A binary 6-mm diameter cut-off did not account for equivocal cases, particularly lymphoid hyperplasia. CONCLUSION: Engagement of sonographers performing pediatric appendiceal ultrasound through training in the scanning technique and awareness of secondary signs significantly improved the visualization rate and provided more meaningful findings to referrers.
Appendicitis* ; Appendix ; Australia ; Child* ; Diagnostic Imaging ; Follow-Up Studies ; Humans ; Hyperplasia ; Pediatrics ; Prospective Studies* ; Retrospective Studies ; Ultrasonography*

OBJECTIVES: Ultrasound has an established role in the diagnostic pathway for children with suspected appendicitis. Relevant clinical information can influence the diagnostic probability and reporting of ultrasound findings. A Bayesian network (BN) is a directed acyclic graph (DAG) representing variables as nodes connected by directional arrows permitting visualisation of their relationships. This research developed a BN model with ultrasonographic and clinical variables to predict acute appendicitis in children. METHODS: A DAG was designed through a hybrid method based on expert opinion and a review of literature to define the model structure; and the discretisation and weighting of identified variables were calculated using principal components analysis, which also informed the conditional probability table of nodes. RESULTS: The acute appendicitis target node was designated as an outcome of interest influenced by four sub-models, including Ultrasound Index, Clinical History, Physical Assessment, and Diagnostic Tests. These sub-models included four sonographic, three blood-test, and six clinical variables. The BN was scenario tested and evaluated for face, predictive, and content validity. A lack of similar networks complicated concurrent and convergent validity evaluation. CONCLUSIONS: To our knowledge, this is the first BN model developed for the identification of acute appendicitis incorporating imaging variables. It has particular benefit for cases in which variables are missing because prior probabilities are built into corresponding nodes. It will be of use to clinicians involved in ultrasound examination of children with suspected appendicitis, as well as their treating clinicians. Prospective evaluation and development of an online tool will permit validation and refinement of the BN.
Appendicitis ; Bayes Theorem ; Child ; Diagnostic Tests, Routine ; Emergency Medicine ; Expert Testimony ; Humans ; Methods ; Pediatrics ; Prospective Studies ; Ultrasonography

PURPOSE: The purpose of this study was to evaluate the ultrasonographic findings of secondary appendicitis (SA) and to discuss the differential findings compared with primary appendicitis. METHODS: In this study, we analyzed the ultrasonographic findings of 94 patients under 15 years old of age treated at our institution from May 2005 to May 2014 who had bowel inflammation and an inflamed appendix with a maximal outer diameter >6 mm that improved with nonsurgical treatment (the SA group). Ninety-nine patients with pathologically proven acute appendicitis (the primary appendicitis [PA] group) from June 2013 to May 2014 and 44 patients with pathologically negative appendectomy results from May 2005 to May 2014 were also included to compare the ultrasonographic features of these conditions. A retrospective review of the ultrasonographic findings was performed by two radiologists. The clinical and laboratory findings were also reviewed. The results were statically analyzed using analysis of variance, the Pearson chi-square test, and the two-tailed Fisher exact test. RESULTS: Compared with PA, cases of SA had a smaller diameter (9.8 mm vs. 6.6 mm, P < 0.001), and were less likely to show periappendiceal fat inflammation (98% vs. 6%, P < 0.001) or an appendicolith (34% vs. 11%, P < 0.001). SA showed mural hyperemia on color Doppler ultrasonography as frequently as PA (P=0.887). CONCLUSION: The ultrasonographic features of SA included an increased diameter compared to a healthy appendix and the same level of hyperemia as in PA. However, the diameter was commonly in the equivocal range (mean diameter, 6.6 mm), and periappendiceal fat inflammation was rarely present in SA.
Appendectomy ; Appendicitis* ; Appendix ; Humans ; Hyperemia ; Inflammation ; Pediatrics ; Retrospective Studies ; Ultrasonography* ; Ultrasonography, Doppler, Color

OBJECTIVE: Owing to advances in laparoscopic technique and equipment, a single-port laparoscopic surgery has been applied in various fields of surgery. However, the application of a single-port laparoscopic surgery for pregnant women has been rarely reported. The aim of this study was to emphasize the feasibility of single-port laparoscopic appendectomy in pregnant women. METHODS: In seven pregnant women who underwent abdominal ultrasonography and physical examination, surgery was performed under the diagnosis of acute appendicitis. In all the patients, single-port laparoscopic appendectomy was performed in the same way. The laparoscopic surgical devices used during surgery were same as those in conventional laparoscopic appendectomy. RESULTS: Age ranged from 25 to 33 years (mean, 29.7 years), gestational age ranged from 7 weeks 3 days to 17 weeks 6 days (mean gestational age, 14 weeks 3 days). The mean operation time was 19 minutes (range, 16–22 minutes). No surgical related complications and any issues occurred. CONCLUSION: Single-port laparoscopic appendectomy for pregnant women is considered one of the treatment methods.
Appendectomy* ; Appendicitis ; Diagnosis ; Female ; Gestational Age ; Humans ; Laparoscopy ; Physical Examination ; Pregnancy ; Pregnant Women* ; Ultrasonography

PURPOSE: We aimed to evaluate whether the modified Alvarado score-which is currently being used to diagnose acute appendicitis-can be applicable in the diagnosis of diseases in pregnant women. METHODS: We retrospectively analyzed the medical records of 252 pregnant women who visited our emergency department (ED) with a chief complaint of abdominal pain and a suspicion of acute appendicitis, and ultimately underwent appendix ultrasonography or appendix magnetic resonance imaging (MRI). The modified Alvarado score was calculated for each pregnant woman. A receiver operating characteristic (ROC) curve was drawn for each subject, those in the first trimester, second trimester, and third trimester, from which the best cut-off value, sensitivity and specificity were induced. RESULTS: For all 252 pregnant women who visited our ED, the area under the curve was 0.742 (p<0.001), with sensitivity and specificity of 75.41% and 62.30%, respectively, when using the value of 5 as the cut-off point for the modified Alvarado score. The area under the curve was 0.811 (p<0.001) for those in their first trimester and 0.749 (p<0.001) for those in the second trimester, while it was 0.641, with the p-value of 0.109, for those in the third trimester. CONCLUSION: There is a limitation using the modified Alvarado score alone in pregnant woman, and if there is uncertainty in the diagnosis, other imaging studies, such as appendix ultrasonography or appendix MRI, should be considered.
Abdominal Pain ; Appendicitis* ; Appendix ; Diagnosis ; Emergency Service, Hospital ; Female ; Humans ; Magnetic Resonance Imaging ; Medical Records ; Pregnancy ; Pregnancy Trimester, First ; Pregnancy Trimester, Second ; Pregnancy Trimester, Third ; Pregnant Women* ; Retrospective Studies ; ROC Curve ; Sensitivity and Specificity ; Ultrasonography ; Uncertainty

PURPOSE: The use of CT as a diagnostic tool in pediatric acute appendicitis is increasing because of its high sensitivity and specificity. However, due to both the serious concerns about radiation of CT and the convenience and reasonable cost of ultrasound (US) examination, US has value on the initial diagnosis of acute appendicitis despite of the lower sensitivity in children. The purpose of this study was to examine the factors that affect the rate of false negative diagnosis of the ultrasound from the patients who received laparoscopic appendectomy. METHODS: The pediatric appendectomy cases from 2002 to 2013 in Yeouido St. Mary's Hospital have been reviewed through the medical records. We included patients who underwent an initial screening by ultrasound examination. RESULTS: Among 181 patients, 156 patients were the sono-positive group and 25 patients were sono-negative group. There is no significant difference in ages, genders, physical examination findings and white blood cell count between the two groups. But, the degree of inflammation of appendicitis (simple, 58.3% vs. 32.0%; complicated, 41.7% vs. 68.0%) and the appendix position (antececal, 85.0% vs. 12.0%; retrocecal, 13.7% vs. 44.0%; pelvic, 1.3% vs. 44.0%) were significantly different between the two groups (sono-positive group vs. sono-negative group; p<0.05). CONCLUSION: The position of the appendix may act as a factor that causes an error in the diagnostic ultrasound, especially, in the retrocecal type and the pelvic type with the higher risk of necrosis or perforation.
Appendectomy ; Appendicitis* ; Appendix ; Child* ; Diagnosis ; Diagnostic Errors* ; Humans ; Inflammation ; Leukocyte Count ; Mass Screening ; Medical Records ; Necrosis ; Physical Examination ; Sensitivity and Specificity ; Ultrasonography*

PURPOSE: This study examined the risk factors of a delayed diagnosis of acute appendicitis in children undergoing an appendectomy. METHODS: This retrospective study involved children aged below 18 years, who underwent an appendectomy. After dividing them into a delayed diagnosis group and nondelayed diagnosis group according to the time interval between the initial hospital visit and final diagnosis, the risk factors of delayed diagnosis were identified using logistic regression analysis. RESULTS: Among 712 patients, 105 patients (14.7%) were classified in the delayed diagnosis group; 92 patients (12.9%) were diagnosed using ultrasonography (US), and both US and computed tomography were performed in 38 patients (5.3%). More patients in the delayed diagnosis group underwent US (P=0.03). Spring season and prior local clinic visit were significantly associated with a delayed diagnosis. Fever and diarrhea were more common in the delayed diagnosis group (fever: odds ratio [OR], 1.37; 95% confidence interval [CI], 1.05–1.81; diarrhea: OR, 1.94; 95% CI, 1.08–3.46; P<0.05). These patients showed symptoms for a longer duration (OR, 2.59; 95% CI, 1.78–3.78; P<0.05), and the admission course (OR, 1.26; 95% CI, 1.11–1.44; P<0.05) and C-reactive protein (CRP) levels (OR, 1.47; 95% CI, 1.19–1.82; P<0.05) were associated with the delayed diagnosis. CONCLUSION: To decrease the rate of delayed diagnoses of acute appendicitis, symptoms such as fever and diarrhea, seasonal variations, admission course, and CRP levels should be considered and children with a longer duration of symptoms should be closely monitored.
Ambulatory Care ; Appendectomy ; Appendicitis* ; C-Reactive Protein ; Child* ; Delayed Diagnosis* ; Diagnosis ; Diarrhea ; Fever ; Humans ; Logistic Models ; Odds Ratio ; Retrospective Studies ; Risk Factors* ; Seasons ; Ultrasonography

In this report, we present a rare case of primary signet-ring cell carcinoma of the appendix in a 51-year-old woman with right lower quadrant pain. Since non-specific concentric appendiceal wall thickening was found in a radiologic evaluation, it was misdiagnosed as non-tumorous appendicitis. An in-depth examination of the correlation between sonographic and histopathologic findings demonstrated that a single markedly thickened hypoechoic layer was well correlated with the diffuse infiltration of tumor cells in both the submucosal and muscle layers. If this sonographic finding is observed in certain clinical settings, such as potential ovarian and peritoneal metastasis, submucosal infiltrative tumors, including signet-ring cell carcinoma, should be considered in the differential diagnosis.
Appendicitis ; Appendix* ; Carcinoma, Signet Ring Cell ; Diagnosis, Differential ; Female ; Humans ; Middle Aged ; Neoplasm Metastasis ; Ultrasonography*