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Appendiceal fecalith is associated with early perforation in pediatric patients
Journal of Pediatric Surgery (2008) 43, 889–892
www.elsevier.com/locate/jpedsurg
Appendiceal fecalith is associated with early perforation in pediatric patients Diya I. Alaedeen, Marc Cook, Walter J. Chwals⁎ Department of Surgery, Division of Pediatric Surgery, Rainbow Babies and Children's Hospital, Case Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH 44106, USA Received 28 November 2007; accepted 3 December 2007
Key words: Fecalith; Appendicolith; Appendiceal perforation; Appendicitis
Abstract Purpose: A fecalith is a fecal concretion that can obstruct the appendix leading to acute appendicitis. We hypothesized that the presence of a fecalith would lead to an earlier appendiceal perforation. Methods: Between January 2001 and December 2005, the charts of all patients younger than 18 years old who underwent appendectomy at our institution were reviewed. Duration of symptoms and timing between presentation and operation were noted along with radiologic, operative, and pathologic findings. Results: There were 388 patients who met the study criteria. A fecalith was present in 31% of patients (n = 121). The appendix was perforated in 57% of patients who had a fecalith vs 36% in patients without a fecalith (P b .001). The overall rate of interval appendectomies was 12%. A fecalith was present on the initial radiologic studies of 36% of the patients who had interval appendectomies, and the appendix was perforated significantly sooner in these patients when compared to those without a fecalith (91 vs 150 hours; P = .036). Conclusion: The presence of fecalith is associated with earlier and higher rates of appendiceal perforation in pediatric patients with acute appendicitis. An expedient appendectomy should therefore be performed in the pediatric patient with a radiologic evidence of fecalith. © 2008 Elsevier Inc. All rights reserved.
Acute appendicitis represents the most common diagnosis requiring an emergent or urgent operative procedure in pediatric surgery and accounts for approximately 80,000 procedures yearly in the United States [1]. In at least one third of these cases, perforation of the appendix has occurred by the time the child presents for surgical evaluation [2,3]. Because appendiceal perforation can be associated with a substantially increased risk of morbidity, hospital length of Presented at the 39th Annual Meeting of the Canadian Association of Pediatric Surgeons, August 23-26, 2007, St John's Newfoundland, Canada. ⁎ Corresponding author. Tel.: +1 216 844 3015; fax: +1 216 844 6867. E-mail address: [email protected] (W.J. Chwals). 0022-3468/$ – see front matter © 2008 Elsevier Inc. All rights reserved. doi:10.1016/j.jpedsurg.2007.12.034
stay, and cost [3,4], it is important to identify factors associated with early perforation. An appendicolith, or fecalith, is a hard, stony mass of feces that can obstruct the appendix. In theory, this obstruction can lead to bacterial overgrowth and increased pressure in the appendiceal lumen [5,6]. As the appendix becomes swollen and edematous, it eventually becomes ischemic and susceptible to rupture. The hard fecal calculus has led to speculation that the mass effect against the appendiceal wall causes erosion. This event potentially leads to earlier focal perforation and more widespread contamination of the peritoneal cavity before more gradual and generalized inflammatory change in the periappendiceal
890 area, more typically induced by obstruction without erosion, has a chance to wall off the gangrenous appendix. Although the rate of appendiceal rupture in the pediatric population is 35% to 60%, an appendicolith is only seen on plain abdominal films in 15% of pediatric patients presenting with appendicitis [2,3]. With the increased use of computed tomographic (CT) imaging to evaluate children who present with a clinical suspicion of acute appendicitis, the incidence of reported appendicoliths in association with this diagnosis has increased to as high as 50% [7]. The hypothesis of this study is that appendiceal rupture occurs more frequently, and earlier, in association with the presence of an appendicolith in children with acute appendicitis.
1. Methods The study was approved by the institutional review boards at the University Hospitals of Cleveland and the Rainbow Babies and Children's Hospital (Cleveland, Ohio). Between January 2001 and December 2005, the charts of all pediatric patients (b18 years old) who underwent appendectomy for the primary treatment of appendicitis at our institution were reviewed. Age, sex, presenting symptoms and their duration, preoperative CT scan and laboratory studies, and operative and pathologic findings were tabulated and analyzed. During the study period, a CT scan with oral and rectal contrast was routinely performed in pediatric patients with suspected appendicitis at our institution. Perforation of the appendix was determined to be present if noted at the time of operation and/or on pathologic assessment of the tissue submitted or in the event of initial nonoperative therapy, if an abscess cavity with enhancing rim or fluid collection containing extramural air was noted to be present on CT imaging. Operative, pathologic, and/or CT imaging findings were used to determine the presence or absence of an appendicolith. Children who presented with right lower quadrant pain, fever, and elevated serum C-reactive protein (CRP) levels in association with abscess formation on CT imaging were assigned a diagnosis of perforated appendicitis. A subset of these patients was initially treated nonoperatively with a 2-week course of intravenous, broad-spectrum antibiotics as well as percutaneous drainage of abscesses greater than 2 cm in diameter. In general, 4 to 6 weeks later, an interval appendectomy was performed. Student's t test and χ2 analyses were used to establish statistical significance at P b .05.
2. Results There were 341 (88%) of 388 patients who underwent an appendectomy primarily for the treatment of acute
D.I. Alaedeen et al. appendicitis at our institution during the study period. An additional 47 children (12%) with CT-confirmed perforation and abscess underwent primary CT-guided percutaneous drainage and 2 weeks of broad-spectrum antibiotic therapy followed by an interval appendectomy. There were 231 males and 157 females with a male-to-female ratio of 3:2 and an average age of 9.8 years. The most common presenting symptoms were right lower quadrant pain (92%), nausea, vomiting, or anorexia (63%), fever (35%), diarrhea (10%), and generalized abdominal or back pain (3%). The perforation rate at the time of presentation was 42% (163/388). A preoperative CT scan was performed in 315 patients (81%). An appendicolith was detected on 30% of the CT scans performed (n = 95). The pathologic records were available for 385 patients. Forty-seven patients had a normal appendix resulting in a negative appendectomy rate of 12.2%. Four patients (0.03%) with negative appendectomies had an appendicolith present on their initial preoperative radiologic findings. An appendicolith was present on CT imaging, intraoperative inspection, or pathologic review in 31% of the patients (n = 121). The appendix was perforated in 57% (69/ 121) of patients who had an appendicolith vs 36% (95/264) of patients without an appendicolith (P b .001). Patients with an appendicolith had higher presenting serum CRP levels than those without an appendicolith (11.1 vs 8.2 mg/dL; P = .035), but there was no difference in the white cell count (WCC) between the 2 groups (15.1 vs 14.3 × 109/L, P = .35). Furthermore, excluding the patients who underwent interval appendectomies, serum CRP concentrations were significantly higher in patients presenting with acute perforation than those without perforation (14.5 vs 4.2 mg/dL; P b .001). The overall rate of interval appendectomies was 12% (47/388). An appendicolith was present on the initial CT imaging of 36% of the patients who had interval appendectomies, and these patients had a shorter interval between onset of symptoms and presentation with perforation when compared to those without an appendicolith (91 vs 150 hours; P = .036).
3. Discussion In the 1930s, Wangensteen [6] published his classic work that established the presence of obstruction as the definitive etiology of acute appendicitis. Today, the association between the presence of a radiographically identified appendicolith and appendicitis is a well-documented and generally well-accepted phenomenon, though some clinical questions remain. One issue is the incidence of appendicoliths in normal appendices; although usually less than 3% in most series [8], higher incidence has been reported [9]. These findings may, in part, be because of improved CT technology used in imaging the appendix. In addition, the presence of an
Appendiceal fecalith in pediatric patients appendicolith has been proposed as an etiologic factor in the chronic appendicitis syndrome described in the adults [10]. The issue of specificity and sensitivity in confirming the diagnosis of acute appendicitis based on the visualization of an appendicolith is unclear. Some authors have reported an association between appendicolith presence and acute appendicitis with up to 100% sensitivity [11], whereas other authors have observed substantially lower predictive values [9,12], primarily because of the incidence of appendicoliths in normal appendices. In this study, we have demonstrated that the presence of an appendicolith is associated with a higher perforation rate in children with acute appendicitis. These findings are consistent with previous retrospective observations in both adult and pediatric patients [13-15]. Erosion of the appendicolith through the wall of the appendix may be an additional mechanism of perforation, potentially leading to earlier rupture and more rapid contamination of the peritoneal cavity. In an attempt to define risk factors associated with complications after appendectomy for treatment of appendiceal perforation, authors of a retrospective, multicenter, case-control study, using regression analysis to establish a multivariable model, found that the intraoperative presence of an appendicolith was 1 of only 2 factors (the other is preoperative diarrhea) influencing the development of postoperative abscess formation [16]. This finding also suggests the possibility that more extensive peritoneal contamination results from appendicolith-associated appendiceal perforation and further raises the question of whether erosion of the fecal calculus through the wall of the appendix might result in earlier perforation with the potential of a longer duration of peritonitis before surgical intervention. In the present study, patients with an appendicolith had significantly higher presenting serum CRP levels than those without an appendicolith, whereas no significant difference was observed in the WCC between the 2 groups. These data demonstrate a greater inflammatory response and increased injury severity when acute appendicitis is associated with the presence of an appendicolith in our patient population. Serum CRP values reflect the acute phase protein response to injury stimuli and have been shown to correlate well with injury severity [17]. Metabolic stress response analysis using CRP has been shown to be valuable in stratifying the magnitude and duration of injury and in predicting outcome after injury in a variety of patient populations [18-21]. A recent prospective study of children with acute appendicitis showed improved sensitivity and specificity of serum CRP levels in contrast to WCC when diagnosing appendiceal perforation [22]. These observations are consistent with previous data that show that CRP values are significantly higher in children with perforated appendicitis [23] and are in agreement with our findings. Twelve percent of the children in the present study presented with right lower quadrant abscess formation consistent with a clinical picture of acute perforated
891 appendicitis. In this patient population, the presence of an appendicolith was associated with a significantly shorter time interval between the onset of symptoms and presentation with perforation relative to patients without an appendicolith. Although the study parameters do not allow for a precise measure of exactly when the perforation actually occurred, it is our assumption that the potential variability about this determination would be about equally distributed between the children with and without an associated appendicolith. If this assumption is valid, then these data strongly suggest that the presence of an appendicolith in a child with the clinical features of acute appendicitis substantially increases the risk of earlier perforation. In the event that appendiceal perforation has not yet occurred, an appendectomy should therefore be performed as early as possible in children with acute appendicitis associated with an appendicolith. On the basis of the results of this study, we currently prioritize the children who have clinical findings consistent with acute nonperforated appendicitis and radiologic evidence of appendicolith to undergo an emergent appendectomy.
References [1] Lund DP, Folkman J. Appendicitis. In: Walker WA, Durie PR, Hamilton JR, et al, editors. Pediatric gastrointestinal disease: pathophysiology, diagnosis, and management. 2nd ed. St Louis (Mo): Mosby; 1996. p. 907-15. [2] Bratton SL, Haberkern CM, Waldhausen JH. Acute appendicitis risks of complications: age and Medicaid insurance. Pediatrics 2000;106: 75-8. [3] Jablonski KA, Guagliardo MF. Pediatric appendicitis rupture rate: a national indicator of disparities in healthcare access. Popul Health Metr 2005;3:4. [4] Chen C, Botelho C, Cooper A, et al. Current practice patterns in the treatment of perforated appendicitis in children. J Am Coll Surg 2003; 196:212-21. [5] Pieper R, Kager L, Tidefeldt U. Obstruction of appendix vermiformis causing acute appendicitis. An experimental study in the rabbit. Acta Chir Scand 1981;148:63-71. [6] Wangensteen OH, Dennis C. Experimental proof of the obstructive origin of appendicitis in man. Ann Surg 1939;110:629-47. [7] Friedland JA, Siegel MJ. CT appearance of acute appendicitis in childhood. AJR Am J Roentgenol 1997;168:439-42. [8] Applegate KE, Sivit CJ, Myers MT, et al. Using helical CT to diagnosis acute appendicitis in children: spectrum of findings. AJR Am J Roentgenol 2001;176:501-5. [9] Benjaminov O, Atri M, Hamilton P, et al. Frequency of visualization and thickness of normal appendix at nonenhanced helical CT. Radiology 2002;225:400-6. [10] Giuliano V, Giuliano C, Pinto F, et al. Chronic appendicitis “syndrome” manifested by an appendicolith and thickened appendix presenting as chronic right lower abdominal pain in adults. Emerg Radiol 2006;12:96-8. [11] Rao PM, Rhea JT, Novelline RA. Helical computed tomographic incidence and characterization of appendoliths in 100 patients with appendicitis. Emerg Radiol 1997;4:55-61. [12] Lowe LH, Penney MW, Scheker LE, et al. Appendicolith revealed on CT in children with suspected appendicitis: how specific is it in the diagnosis of appendicitis? AJR Am J Roentgenol 2000;175:981-4.
892 [13] Brender JD, Marcuse EK, Koepsell TD, et al. Childhood appendicitis: factors associated with perforation. Pediatrics 1985;76:301-6. [14] Nitecki S, Karmeli R, Sarr MG. Appendiceal calculi and fecaliths as indications for appendectomy. Surg Gynecol Obstet 1990;171:185-8. [15] Ditillo MF, Dziura JD, Rabinovici R. Is it safe to delay appendectomy in adults with acute appendicitis? Ann Surg 2006;244:656-60. [16] Henry MC, Walker A, Silverman BL, et al. Risk factors for the development of abdominal abscess following operation for perforated appendicitis in children: a multicenter case-control study. Arch Surg 2007;142:236-41. [17] Letton RW, Chwals WJ, Jamie A, et al. Neonatal lipid utilization increases with injury severity: recombinant human growth hormone versus placebo. J Pediatr Surg 1996;31:1068-74. [18] Chwals WJ, Fernandez ME, Jamie AC, et al. Detection of postoperative sepsis in infants with the use of metabolic stress monitoring. Arch Surg 1994;129:437-42.
D.I. Alaedeen et al. [19] Alaedeen DI, Queen AL, Leung E, et al. C-Reactive proteindetermined injury severity: length of stay predictor in surgical infants. J Pediatr Surg 2004;39:1832-4. [20] O Connor E, Venkatesh B, Mashongonyika C, et al. Serum procalcitonin and C-reactive protein as markers of sepsis and outcome in patients with neurotrauma and subarachnoid haemorrhage. Anaesth Intensive Care 2004;32:465-70. [21] Neely AN, Smith WL, Warden G. Efficacy of a rise in C-reactive protein serum levels as an early indicator of sepsis in burned children. J Burn Care Rehabil 1998;19:102-5. [22] Sack U, Biereder B, Elouahidi T, et al. Diagnostic value of blood inflammatory markers for detection of acute appendicitis in children. BMC Surg 2006;6:15. [23] Chung JL, Kong MS, Lin SL, et al. Diagnostic value of C-reactive protein in children with perforated appendicitis. Eur J Pediatr 1996; 155:529-31.
www.elsevier.com/locate/jpedsurg
Appendiceal fecalith is associated with early perforation in pediatric patients Diya I. Alaedeen, Marc Cook, Walter J. Chwals⁎ Department of Surgery, Division of Pediatric Surgery, Rainbow Babies and Children's Hospital, Case Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH 44106, USA Received 28 November 2007; accepted 3 December 2007
Key words: Fecalith; Appendicolith; Appendiceal perforation; Appendicitis
Abstract Purpose: A fecalith is a fecal concretion that can obstruct the appendix leading to acute appendicitis. We hypothesized that the presence of a fecalith would lead to an earlier appendiceal perforation. Methods: Between January 2001 and December 2005, the charts of all patients younger than 18 years old who underwent appendectomy at our institution were reviewed. Duration of symptoms and timing between presentation and operation were noted along with radiologic, operative, and pathologic findings. Results: There were 388 patients who met the study criteria. A fecalith was present in 31% of patients (n = 121). The appendix was perforated in 57% of patients who had a fecalith vs 36% in patients without a fecalith (P b .001). The overall rate of interval appendectomies was 12%. A fecalith was present on the initial radiologic studies of 36% of the patients who had interval appendectomies, and the appendix was perforated significantly sooner in these patients when compared to those without a fecalith (91 vs 150 hours; P = .036). Conclusion: The presence of fecalith is associated with earlier and higher rates of appendiceal perforation in pediatric patients with acute appendicitis. An expedient appendectomy should therefore be performed in the pediatric patient with a radiologic evidence of fecalith. © 2008 Elsevier Inc. All rights reserved.
Acute appendicitis represents the most common diagnosis requiring an emergent or urgent operative procedure in pediatric surgery and accounts for approximately 80,000 procedures yearly in the United States [1]. In at least one third of these cases, perforation of the appendix has occurred by the time the child presents for surgical evaluation [2,3]. Because appendiceal perforation can be associated with a substantially increased risk of morbidity, hospital length of Presented at the 39th Annual Meeting of the Canadian Association of Pediatric Surgeons, August 23-26, 2007, St John's Newfoundland, Canada. ⁎ Corresponding author. Tel.: +1 216 844 3015; fax: +1 216 844 6867. E-mail address: [email protected] (W.J. Chwals). 0022-3468/$ – see front matter © 2008 Elsevier Inc. All rights reserved. doi:10.1016/j.jpedsurg.2007.12.034
stay, and cost [3,4], it is important to identify factors associated with early perforation. An appendicolith, or fecalith, is a hard, stony mass of feces that can obstruct the appendix. In theory, this obstruction can lead to bacterial overgrowth and increased pressure in the appendiceal lumen [5,6]. As the appendix becomes swollen and edematous, it eventually becomes ischemic and susceptible to rupture. The hard fecal calculus has led to speculation that the mass effect against the appendiceal wall causes erosion. This event potentially leads to earlier focal perforation and more widespread contamination of the peritoneal cavity before more gradual and generalized inflammatory change in the periappendiceal
890 area, more typically induced by obstruction without erosion, has a chance to wall off the gangrenous appendix. Although the rate of appendiceal rupture in the pediatric population is 35% to 60%, an appendicolith is only seen on plain abdominal films in 15% of pediatric patients presenting with appendicitis [2,3]. With the increased use of computed tomographic (CT) imaging to evaluate children who present with a clinical suspicion of acute appendicitis, the incidence of reported appendicoliths in association with this diagnosis has increased to as high as 50% [7]. The hypothesis of this study is that appendiceal rupture occurs more frequently, and earlier, in association with the presence of an appendicolith in children with acute appendicitis.
1. Methods The study was approved by the institutional review boards at the University Hospitals of Cleveland and the Rainbow Babies and Children's Hospital (Cleveland, Ohio). Between January 2001 and December 2005, the charts of all pediatric patients (b18 years old) who underwent appendectomy for the primary treatment of appendicitis at our institution were reviewed. Age, sex, presenting symptoms and their duration, preoperative CT scan and laboratory studies, and operative and pathologic findings were tabulated and analyzed. During the study period, a CT scan with oral and rectal contrast was routinely performed in pediatric patients with suspected appendicitis at our institution. Perforation of the appendix was determined to be present if noted at the time of operation and/or on pathologic assessment of the tissue submitted or in the event of initial nonoperative therapy, if an abscess cavity with enhancing rim or fluid collection containing extramural air was noted to be present on CT imaging. Operative, pathologic, and/or CT imaging findings were used to determine the presence or absence of an appendicolith. Children who presented with right lower quadrant pain, fever, and elevated serum C-reactive protein (CRP) levels in association with abscess formation on CT imaging were assigned a diagnosis of perforated appendicitis. A subset of these patients was initially treated nonoperatively with a 2-week course of intravenous, broad-spectrum antibiotics as well as percutaneous drainage of abscesses greater than 2 cm in diameter. In general, 4 to 6 weeks later, an interval appendectomy was performed. Student's t test and χ2 analyses were used to establish statistical significance at P b .05.
2. Results There were 341 (88%) of 388 patients who underwent an appendectomy primarily for the treatment of acute
D.I. Alaedeen et al. appendicitis at our institution during the study period. An additional 47 children (12%) with CT-confirmed perforation and abscess underwent primary CT-guided percutaneous drainage and 2 weeks of broad-spectrum antibiotic therapy followed by an interval appendectomy. There were 231 males and 157 females with a male-to-female ratio of 3:2 and an average age of 9.8 years. The most common presenting symptoms were right lower quadrant pain (92%), nausea, vomiting, or anorexia (63%), fever (35%), diarrhea (10%), and generalized abdominal or back pain (3%). The perforation rate at the time of presentation was 42% (163/388). A preoperative CT scan was performed in 315 patients (81%). An appendicolith was detected on 30% of the CT scans performed (n = 95). The pathologic records were available for 385 patients. Forty-seven patients had a normal appendix resulting in a negative appendectomy rate of 12.2%. Four patients (0.03%) with negative appendectomies had an appendicolith present on their initial preoperative radiologic findings. An appendicolith was present on CT imaging, intraoperative inspection, or pathologic review in 31% of the patients (n = 121). The appendix was perforated in 57% (69/ 121) of patients who had an appendicolith vs 36% (95/264) of patients without an appendicolith (P b .001). Patients with an appendicolith had higher presenting serum CRP levels than those without an appendicolith (11.1 vs 8.2 mg/dL; P = .035), but there was no difference in the white cell count (WCC) between the 2 groups (15.1 vs 14.3 × 109/L, P = .35). Furthermore, excluding the patients who underwent interval appendectomies, serum CRP concentrations were significantly higher in patients presenting with acute perforation than those without perforation (14.5 vs 4.2 mg/dL; P b .001). The overall rate of interval appendectomies was 12% (47/388). An appendicolith was present on the initial CT imaging of 36% of the patients who had interval appendectomies, and these patients had a shorter interval between onset of symptoms and presentation with perforation when compared to those without an appendicolith (91 vs 150 hours; P = .036).
3. Discussion In the 1930s, Wangensteen [6] published his classic work that established the presence of obstruction as the definitive etiology of acute appendicitis. Today, the association between the presence of a radiographically identified appendicolith and appendicitis is a well-documented and generally well-accepted phenomenon, though some clinical questions remain. One issue is the incidence of appendicoliths in normal appendices; although usually less than 3% in most series [8], higher incidence has been reported [9]. These findings may, in part, be because of improved CT technology used in imaging the appendix. In addition, the presence of an
Appendiceal fecalith in pediatric patients appendicolith has been proposed as an etiologic factor in the chronic appendicitis syndrome described in the adults [10]. The issue of specificity and sensitivity in confirming the diagnosis of acute appendicitis based on the visualization of an appendicolith is unclear. Some authors have reported an association between appendicolith presence and acute appendicitis with up to 100% sensitivity [11], whereas other authors have observed substantially lower predictive values [9,12], primarily because of the incidence of appendicoliths in normal appendices. In this study, we have demonstrated that the presence of an appendicolith is associated with a higher perforation rate in children with acute appendicitis. These findings are consistent with previous retrospective observations in both adult and pediatric patients [13-15]. Erosion of the appendicolith through the wall of the appendix may be an additional mechanism of perforation, potentially leading to earlier rupture and more rapid contamination of the peritoneal cavity. In an attempt to define risk factors associated with complications after appendectomy for treatment of appendiceal perforation, authors of a retrospective, multicenter, case-control study, using regression analysis to establish a multivariable model, found that the intraoperative presence of an appendicolith was 1 of only 2 factors (the other is preoperative diarrhea) influencing the development of postoperative abscess formation [16]. This finding also suggests the possibility that more extensive peritoneal contamination results from appendicolith-associated appendiceal perforation and further raises the question of whether erosion of the fecal calculus through the wall of the appendix might result in earlier perforation with the potential of a longer duration of peritonitis before surgical intervention. In the present study, patients with an appendicolith had significantly higher presenting serum CRP levels than those without an appendicolith, whereas no significant difference was observed in the WCC between the 2 groups. These data demonstrate a greater inflammatory response and increased injury severity when acute appendicitis is associated with the presence of an appendicolith in our patient population. Serum CRP values reflect the acute phase protein response to injury stimuli and have been shown to correlate well with injury severity [17]. Metabolic stress response analysis using CRP has been shown to be valuable in stratifying the magnitude and duration of injury and in predicting outcome after injury in a variety of patient populations [18-21]. A recent prospective study of children with acute appendicitis showed improved sensitivity and specificity of serum CRP levels in contrast to WCC when diagnosing appendiceal perforation [22]. These observations are consistent with previous data that show that CRP values are significantly higher in children with perforated appendicitis [23] and are in agreement with our findings. Twelve percent of the children in the present study presented with right lower quadrant abscess formation consistent with a clinical picture of acute perforated
891 appendicitis. In this patient population, the presence of an appendicolith was associated with a significantly shorter time interval between the onset of symptoms and presentation with perforation relative to patients without an appendicolith. Although the study parameters do not allow for a precise measure of exactly when the perforation actually occurred, it is our assumption that the potential variability about this determination would be about equally distributed between the children with and without an associated appendicolith. If this assumption is valid, then these data strongly suggest that the presence of an appendicolith in a child with the clinical features of acute appendicitis substantially increases the risk of earlier perforation. In the event that appendiceal perforation has not yet occurred, an appendectomy should therefore be performed as early as possible in children with acute appendicitis associated with an appendicolith. On the basis of the results of this study, we currently prioritize the children who have clinical findings consistent with acute nonperforated appendicitis and radiologic evidence of appendicolith to undergo an emergent appendectomy.
References [1] Lund DP, Folkman J. Appendicitis. In: Walker WA, Durie PR, Hamilton JR, et al, editors. Pediatric gastrointestinal disease: pathophysiology, diagnosis, and management. 2nd ed. St Louis (Mo): Mosby; 1996. p. 907-15. [2] Bratton SL, Haberkern CM, Waldhausen JH. Acute appendicitis risks of complications: age and Medicaid insurance. Pediatrics 2000;106: 75-8. [3] Jablonski KA, Guagliardo MF. Pediatric appendicitis rupture rate: a national indicator of disparities in healthcare access. Popul Health Metr 2005;3:4. [4] Chen C, Botelho C, Cooper A, et al. Current practice patterns in the treatment of perforated appendicitis in children. J Am Coll Surg 2003; 196:212-21. [5] Pieper R, Kager L, Tidefeldt U. Obstruction of appendix vermiformis causing acute appendicitis. An experimental study in the rabbit. Acta Chir Scand 1981;148:63-71. [6] Wangensteen OH, Dennis C. Experimental proof of the obstructive origin of appendicitis in man. Ann Surg 1939;110:629-47. [7] Friedland JA, Siegel MJ. CT appearance of acute appendicitis in childhood. AJR Am J Roentgenol 1997;168:439-42. [8] Applegate KE, Sivit CJ, Myers MT, et al. Using helical CT to diagnosis acute appendicitis in children: spectrum of findings. AJR Am J Roentgenol 2001;176:501-5. [9] Benjaminov O, Atri M, Hamilton P, et al. Frequency of visualization and thickness of normal appendix at nonenhanced helical CT. Radiology 2002;225:400-6. [10] Giuliano V, Giuliano C, Pinto F, et al. Chronic appendicitis “syndrome” manifested by an appendicolith and thickened appendix presenting as chronic right lower abdominal pain in adults. Emerg Radiol 2006;12:96-8. [11] Rao PM, Rhea JT, Novelline RA. Helical computed tomographic incidence and characterization of appendoliths in 100 patients with appendicitis. Emerg Radiol 1997;4:55-61. [12] Lowe LH, Penney MW, Scheker LE, et al. Appendicolith revealed on CT in children with suspected appendicitis: how specific is it in the diagnosis of appendicitis? AJR Am J Roentgenol 2000;175:981-4.
892 [13] Brender JD, Marcuse EK, Koepsell TD, et al. Childhood appendicitis: factors associated with perforation. Pediatrics 1985;76:301-6. [14] Nitecki S, Karmeli R, Sarr MG. Appendiceal calculi and fecaliths as indications for appendectomy. Surg Gynecol Obstet 1990;171:185-8. [15] Ditillo MF, Dziura JD, Rabinovici R. Is it safe to delay appendectomy in adults with acute appendicitis? Ann Surg 2006;244:656-60. [16] Henry MC, Walker A, Silverman BL, et al. Risk factors for the development of abdominal abscess following operation for perforated appendicitis in children: a multicenter case-control study. Arch Surg 2007;142:236-41. [17] Letton RW, Chwals WJ, Jamie A, et al. Neonatal lipid utilization increases with injury severity: recombinant human growth hormone versus placebo. J Pediatr Surg 1996;31:1068-74. [18] Chwals WJ, Fernandez ME, Jamie AC, et al. Detection of postoperative sepsis in infants with the use of metabolic stress monitoring. Arch Surg 1994;129:437-42.
D.I. Alaedeen et al. [19] Alaedeen DI, Queen AL, Leung E, et al. C-Reactive proteindetermined injury severity: length of stay predictor in surgical infants. J Pediatr Surg 2004;39:1832-4. [20] O Connor E, Venkatesh B, Mashongonyika C, et al. Serum procalcitonin and C-reactive protein as markers of sepsis and outcome in patients with neurotrauma and subarachnoid haemorrhage. Anaesth Intensive Care 2004;32:465-70. [21] Neely AN, Smith WL, Warden G. Efficacy of a rise in C-reactive protein serum levels as an early indicator of sepsis in burned children. J Burn Care Rehabil 1998;19:102-5. [22] Sack U, Biereder B, Elouahidi T, et al. Diagnostic value of blood inflammatory markers for detection of acute appendicitis in children. BMC Surg 2006;6:15. [23] Chung JL, Kong MS, Lin SL, et al. Diagnostic value of C-reactive protein in children with perforated appendicitis. Eur J Pediatr 1996; 155:529-31.