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Acute appendicitis is a frequent surgical emergency in children, and early recognition of severe forms remains challenging. This prospective observational study compared the Appendicitis Inflammatory Response (AIR) and Pediatric Appendicitis Score (PAS) for grading disease severity in pediatric acute appendicitis. Among 542 children assessed, 138 with suspected appendicitis were included, and 136 underwent appendectomy. All included patients were prospectively scored with AIR and PAS, and clinical, radiologic, intraoperative, and histopathologic findings were recorded. Associations between score categories and complicated appendicitis (gangrenous, abscess, or diffuse peritonitis) or perforated appendicitis were analyzed, and diagnostic performance was assessed using receiver operating characteristic curves. Higher AIR and PAS categories were associated with increasing appendix diameter; AIR categories were significantly associated with both complicated appendicitis and perforation, whereas PAS categories were significantly associated only with perforation. For complicated appendicitis, the area under the curve (AUC) was slightly higher for AIR than PAS, whereas for perforation both scores showed similar AUCs. These findings suggest that AIR is more informative than PAS for overall grading of disease severity in pediatric acute appendicitis, while AIR and PAS provide comparable, moderate accuracy for predicting perforation.

Background Acute appendicitis is the most common surgical condition of children. Differential diagnosis of an acutely inflamed appendix in children includes a vast variety of diseases which can present with the same symptoms and signs as acute appendicitis. It is an important factor for delay in diagnosis. Many scoring systems are being used to reach a diagnosis within time and to reduce the rate of negative appendectomies. The purpose of this study was to compare both scoring systems (Alvarado and pediatric appendicitis scoring system) and to know which one is better to establish an early correct diagnosis of acute appendicitis in pediatrics, thus decreasing the morbidity and burden on hospital resources. Although many studies had been completed at the international level for comparing both of these scoring systems, the pediatric population in our region was still awaiting such an effort. So a prospective cohort study was designed. A total of 180 patients were recruited with 95% confidence level and 5% margin of error. Every enrolled patient was awarded clinical scores according to both the Alvarado scoring system and the pediatric appendicitis scoring system. Patients having a score of 7 or more by both scoring systems were considered “seven or more than seven group” and their appendectomies were performed and histopathology reports were reviewed. Patients having a score of 7 in one system and less than 7 in the other/both were considered “less than seven group” and were admitted in the ward for further clinical evaluation and observation. Results At cutoff 7, the Alvarado score showed a sensitivity of 85.5%, specificity of 70%, PPV of 96.5%, NPV of 33.3%, and diagnostic accuracy of 84.11% while the pediatric appendicitis score showed a sensitivity of 93.8%, specificity of 70%, PPV of 96.8%, NPV of 53.8, and diagnostic accuracy of 91.59%. Conclusion The pediatric appendicitis score (PAS) is superior in diagnosing acute appendicitis in the pediatric population than the Alvarado score as indicated by the values of diagnostic accuracy. So it can be a good diagnostic tool for pediatric patients presenting with clinical symptoms and signs of appendicitis.

Background Acute appendicitis is classified into simple (SA) and complicated (CA). Ultrasound scans (USS) can be useful in clinically equivocal cases, by visualising primary and secondary signs. This study explores the utility of sonographic signs to diagnose and differentiate appendicitis in children. Methods Single-centre retrospective cohort study over a 2-year period. Consecutive USS for suspected appendicitis were included; sonographic signs were extracted from standardised institutional worksheets. USS results were compared with pre-defined intraoperative criteria for SA and CA, confirmed with histological analysis. Data are reported as median [interquartile range], percentages (number), area under the curve (AUC), conventional diagnostic formulae and adjusted odds ratios following multiple logistic regression ( p  < 0.05 considered significant). Results A total of 934 USS were included, with median age 10.7 [8.0–13.4] years, majority were female (54%). One quarter ( n  = 226) had SA, 12% ( n  = 113) had CA, 61% ( n  = 571) had no appendectomy and 3% ( n  = 24) had negative appendicectomy. Appendix visualisation rate on USS was 61% ( n  = 569), with 62% ( n  = 580) having a conclusive report. Sonographic signs suggesting appendicitis included an appendiceal diameter > 7 mm (AUC 0.92, [95% CI: 0.90–0.94]), an appendicolith ( p  = 0.003), hyperaemia ( p  = 0.001), non-compressibility ( p  = 0.029) and no luminal gas ( p  = 0.004). Secondary sonographic signs included probe tenderness ( p  < 0.001) and peri-appendiceal echogenic fat ( p  < 0.001). Sonographic signs suggesting CA over SA comprised a diameter > 10.1 mm (AUC 0.63, [95% CI: 0.57–0.69]), an appendicolith ( p  = 0.003) and peri-appendiceal fluid ( p  = 0.004). Conclusion Presence of specific sonographic signs can aid diagnosis and differentiation of simple and complicated appendicitis in children.

Background There are currently no definitive or reliable methods for diagnosing complicated appendicitis in preschool children. This study aimed to identify the independent risk factors for complicated appendicitis to assist clinicians in assessing the severity of appendicitis in preschool children. Methods We conducted a retrospective analysis of 258 preschool-aged patients from January 2021 to December 2023, including 99 cases with complicated appendicitis and 159 cases with uncomplicated appendicitis. The characteristics of clinical symptoms and laboratory data were collected, and then the Pediatric Appendicitis Score (PAS) was calculated. Univariate and multivariate analyses were performed to identify the independent risk factors for complicated appendicitis. The receiver operating characteristic (ROC) curve and the area under the ROC curve (AUC) were used to assess the diagnostic performance of these indicators. Results Univariate analysis revealed significant differences in PAS, neutrophil-to-lymphocyte ratio (NLR), and C-reactive protein (CRP) levels between complicated and uncomplicated appendicitis ( p  < 0.05). And these three parameters were also confirmed to be independent risk factors for complicated appendicitis by further multivariate regression analysis. The PAS demonstrated a moderate diagnostic performance in distinguishing complicated appendicitis, with an optimal cut-off value of 8, sensitivity of 77.8% and specificity of 49.1% (AUC: 0.678, 95% CI : 0.614 ~ 0.743). And CRP alone seems to provide a higher AUC of 0.809(95% CI : 0.755–0.864) with the sensitivity of 79.8% and specificity of 76.1%. Additionally, the combination of these three variables yielded a further, albeit marginal, improvement in diagnostic efficacy. Conclusion The PAS, NLR, and CRP are identified as independent predictors for identifying complicated appendicitis. Moreover, the combination of PAS, NLR, and CRP allows clinicians to better differentiate complicated appendicitis, thus facilitating clinical decision-making in preschool children.

Aims: Evaluation of the pediatric appendicitis score (PAS), in all patients who had an appendicectomy over a one-year period. Methods: Retrospective study of 56 patients aged 4-15 years, who underwent an emergency appendicectomy. PAS was applied and patients were divided according to the PAS protocol into high probability and low probability groups. These results were then correlated with histology. Results: The PAS had sensitivity 0.87, specificity 0.59, positive predictive value 0.83, and negative predictive value 0.67. The negative appendicectomy rate would have been reduced to 17%, but five patients with appendicitis would have been denied early surgical treatment and may have been discharged. Conclusions: The PAS cannot be recommended as it would lead to an unacceptable risk of wrongly discharging or delaying necessary surgery in 13% of patients with appendicitis.

Accurate diagnosis of paediatric appendicitis remains a challenge due to its diverse clinical presentations and reliance on subjective assessments. The integration of artificial intelligence (AI) with an expert’s ‘‘clinical sense’’ has the potential to improve diagnostic accuracy. In this study, we aimed to evaluate the effectiveness of the Artificial Intelligence Pediatric Appendicitis Decision-tree (AiPAD) model in enhancing the diagnostic capabilities of trainees and compare their performance with that of an expert supervisor. Between March 2019 and October 2022, we included paediatric patients aged 0–12 years who were referred for suspected appendicitis. Trainees collected clinical findings using five predefined parameters before ordering any imaging studies. The AiPAD model, which was blinded to the surgical team, made predictions from the supervisor’s and trainees’ findings independently. The diagnosis verdicts of the supervisor and the trainees were statistically evaluated in comparison to the prediction of the AI model, taking into account the revealed correct diagnosis. A total of 136 cases were included, comprising 58 cases of acute appendicitis (AA) and 78 cases of non-appendicitis (NA). The supervisor’s correct verdict showed 91% accuracy compared to an average of 70% for trainees. However, if trainees were enabled with AiPAD, their accuracy would improve significantly to an average of 97%. Significantly, a strong association was observed between the expert’s clinical sense and the predictions generated by AiPAD. Conclusion : The utilisation of the AiPAD model in diagnosing paediatric appendicitis has significant potential to improve trainees’ diagnostic accuracy, approaching the level of an expert supervisor. This hybrid approach combining AI and expert knowledge holds promise for enhancing diagnostic capabilities, reducing medical errors and improving patient outcomes. What is Known: • Sharpening clinical judgement for pediatric appendicitis takes time and seasoned exposure. Traditional training leaves junior doctors yearning for a faster path to diagnostic mastery. What is New: • AI-generated models unlock the secrets of expert intuition, crafting an explicit guide for juniors to rapidly elevate their diagnostic skills. This leapfrog advancement empowers young doctors, democratizing medical expertise and paving the way for brighter outcomes in clinical training.

Background Although the neutrophil-to-lymphocyte ratio (NLR) has demonstrated diagnostic utility in appendicitis, its predictive value for postoperative recovery outcomes remains uncertain. This investigation sought to examine the association between preoperative NLR and length of stay (LOS) in pediatric patients who underwent laparoscopic appendectomy. Methods We performed a retrospective analysis of 815 pediatric patients (aged < 18 years) who underwent laparoscopic appendectomy between January 2021 and December 2022 at Suining Central Hospital. The primary exposure variable was preoperative NLR, with postoperative LOS serving as the main outcome measure. Multiple regression models were established, with adjustments for demographic characteristics, clinical parameters, and surgical variables. Results Following comprehensive adjustment, each 10-unit increment in NLR was associated with a 0.19-day prolongation in LOS (95% CI: 0.02, 0.36; P  = 0.025). Stratified analyses demonstrated significant positive correlations in male patients, cases without appendiceal fecalith, patients without drainage tubes, and those with uncomplicated appendicitis (all P  < 0.05). Smooth curve analysis revealed a consistent positive association between NLR and LOS throughout the entire spectrum of NLR values. Conclusion Preoperative NLR demonstrated a positive association with postoperative LOS in pediatric patients undergoing laparoscopic appendectomy, indicating its potential value as a predictive marker for hospital resource utilization and perioperative management optimization.

Objectives To prospectively assess the performance of pediatric appendicitis score (PAS) in diagnosing acute appendicitis in the children with lower abdominal pain and correlated with ultrasound findings; and to assess the impact of the PAS on clinical outcome and its efficacy in differentiating between complicated and uncomplicated appendicitis. Methods A prospective study was done which included cases of lower abdominal pain. Appendectomy was done for PAS ≥ 6, and diagnosis was confirmed on histopathology. A receiver operator characteristic (ROC) curve was created to assess the PAS performance. The sensitivity, specificity, and accuracy of ultrasonography in diagnosing appendicitis were assessed, and analysis of agreement between ultrasonography and PAS score was done by kappa statistics. Results Of 260 cases with lower abdominal pain, 205 were suspected of having appendicitis. One hundred fifty-nine had PAS ≥ 6. There were 2/159 (1.26%) cases of negative appendectomies and 2/46 (4.34%) cases of missed appendicitis. The mean PAS was significantly higher in patients with appendicitis than in those without appendicitis. The area under the ROC curve was 0.9925. Sensitivity, specificity, and positive and negative predictive value of PAS were 98.74%, 95.65%, 95.7% and 95.65%, respectively. Complicated appendicitis had significantly more PAS, fever, and cough tenderness than uncomplicated appendicitis. The sensitivity and specificity of ultrasonography were 86.79% and 17.39%, respectively. Agreement between ultrasonography-proven appendicitis and PAS-dependent appendicitis was weak. Conclusion PAS has high efficacy in diagnosing acute appendicitis. Clinical outcome was more favorable with the use of PAS. Ultrasonography should be used judiciously and in combination with clinical judgment.

Appendicitis is a frequent condition, with peak incidences in the second decade of life. Its pathogenesis is under debate, but bacterial infections are crucial, and antibiotic treatment remains essential. Rare bacteria are accused of causing complications, and various calculated antibiotics are propagated, yet there is no comprehensive microbiological analysis of pediatric appendicitis. Here we review different pre-analytic pathways, identify rare and common bacterial pathogens and their antibiotic resistances, correlate clinical courses, and evaluate standard calculated antibiotics in a large pediatric cohort. We reviewed 579 patient records and microbiological results of intraoperative swabs in standard Amies agar media or fluid samples after appendectomies for appendicitis between May 2011 and April 2019. Bacteria were cultured and identified VITEK 2 or MALDI-TOF MS. Minimal inhibitory concentrations were reevaluated according to EUCAST 2022. Results were correlated to clinical courses. Of 579 analyzed patients, in 372 patients we got 1330 bacterial growths with resistograms. 1259 times, bacteria could be identified to species level. 102 different bacteria could be cultivated. 49% of catarrhal and 52% of phlegmonous appendices resulted in bacterial growth. In gangrenous appendicitis, only 38% remained sterile, while this number reduced to 4% after perforation. Many fluid samples remained sterile even when unsterile swabs had been taken simultaneously. 40 common enteral genera were responsible for 76.5% of bacterial identifications in 96.8% of patients. However, 69 rare bacteria were found in 187 patients without specifically elevated risk for complications. Amies agar gel swabs performed superior to fluid samples and should be a standard in appendectomies. Even catarrhal appendices were only sterile in 51%, which is interesting in view of a possible viral cause. According to our resistograms, the best antibiotic was imipenem with 88.4% susceptible strains, followed by piperacillin-tazobactam, cefuroxime with metronidazole, and ampicillin-sulbactam to which only 21.6% of bacteria were susceptible. Bacterial growths and higher resistances correlate to an elevated risk of complications. Rare bacteria are found in many patients, but there is no specific consequence regarding antibiotic susceptibility, clinical course, or complications. Prospective, comprehensive studies are needed to further elicit pediatric appendicitis microbiology and antibiotic treatment.

PurposeThe study aim is to determine whether serum and urine interleukin-6 (IL-6) and neutrophil gelatinase-associated lipocalin (NGAL) can be included in the early diagnostic algorithm for pediatric appendicitis.MethodsProspective single-center cohort study included 92 children divided into control, acute complicated appendicitis (AcA) and acute uncomplicated appendicitis (AnA) groups. Serum and urine samples were assayed for IL-6 and NGAL preoperatively, and on the second and fifth postoperative days. Intraoperative and bacteriological findings divided the appendicitis patients.ResultsAverage serum biomarker levels were higher in appendicitis patients versus the control, and the following values were produced via receiver operating characteristic (ROC) analysis. NGAL and IL-6 cutoff values were 113.95 ng/ml and 24.64 pg/ml, respectively, NGAL had 68.3% sensitivity and 65.5% specificity, while IL-6 had 72.6% and 86.2%. Comparing AcA and AnA, IL-6 was the only biomarker of significance yielding 77.4% sensitivity and 58.1% specificity with a 26.43 pg/ml cutoff value. Urine biomarkers were non-specific in differentiation appendicitis severity and ultimately, between infectious and non-infectious disease.ConclusionAlthough NGAL provided measurable useful diagnostic information in evaluating children for appendicitis, its values were not sufficient for appendicitis severity. Serum IL-6 remains a strong biomarker for suspected acute appendicitis and has promising results predicting its severity.