| BackgroudAcute appendicitis is one of the most common acute abdomen in children.The incidence of acute appendicitis is 7% to 8% of the world population.Generally,male patients are more than female patients.In the past few years,although acute appendicitis in children is very common,little is known about the pathogenesis of appendicitis,which is usually attributed to intraappendiceal obstruction.Intracavity obstruction leads to increased mucus secretion,excessive growth and deposition of bacteria,which increases the tension of the appendix wall,reduces blood flow and lymphatic reflux,and eventually leads to appendix necrosis and perforation.Another recognized important reason is bacterial invasion,pathogenic bacteria invasion into the appendix cavity,causing bacterial overgrowth is leading to the breakdown of the mucosal barrier,bacterial invasion of the appendix wall,leading to inflammation,ischemia and gangrene and eventually leading to perforation.In addition,in recent years,the pathogenesis of acute appendicitis is considered to be related to genetic factors,environmental factors and so on.At present,owing to the particularity of children,it is still a challenge to obtain rapid and accurate diagnosis.History,physical examination and laboratory examination results are helpful in the diagnosis of acute appendicitis.Limited fixed tenderness in the right lower abdomen and abdominal muscle tension are the most valuable signs.However,due to the unclear description of the history in children or the weak abdominal wall in children,abdominal muscle tension is not obvious.Therefore,the history of acute appendicitis in children has certain limitations in the diagnosis of acute appendicitis.Several diagnostic scoring systems have been established internationally for clinical manifestations,among which Alvarado scoring system is the most commonly used one.However,only the scoring system is not enough to diagnose acute appendicitis.It needs the support of imaging examinations,such as ultrasound and CT,in order to improve the accuracy,sensitivity and specificity of the diagnosis of acute appendicitis in children.Studies have shown that delayed diagnosis can increase appendicitis in children.Some people believe that once acute appendicitis is diagnosed,appendectomy should be performed immediately to prevent the development of appendicitis and reduce the incidence of appendicitis perforation rate and other complications.However,some studies have shown that interval appendectomy has no effect on the prognosis of acute appendicitis in children,that is,children use antibiotics at night and then have appendectomy the next morning.Therefore,despite the high incidence of appendicitis in children,there is still a lack of consensus on the best time for appendectomy.PurposeThe diagnostic value of US,CT and Alvarado scores in children with appendicitis was analyzed by clinical case analysis.The diagnostic value of CT and US in children with appendicitis was compared,and the projection distribution area of appendicitis on body surface was discussed according to CT images.MethodsThe clinical data of 397 children with acute appendicitis(379 cases of acute appendicitis confirmed by routine pathology and 18 cases of non-acute appendicitis)diagnosed by pediatric surgery in the First Affiliated Hospital of Zhengzhou University from March 2013 to February 2017 were retrospectively analyzed.Among them,228 children underwent CT examination,320 children underwent ultrasound examination,and 185 children underwent CT and ultrasound examination at the same time.185 children who underwent both CT and ultrasound examination were analyzed.According to the Alvarado score,they were divided into three groups: 0-4,5-7 and(> 7).The sensitivity,specificity,accuracy,positive predictive value and negative predictive value of Alvarado score,CT examination,ultrasound examination and combined diagnosis of acute appendicitis in children were analyzed according to the pathological results of acute appendicitis as the gold standard.According to the pathological results,the children were divided into four groups: simple appendix,suppurative appendicitis,gangrenous appendicitis and periappendiceal abscess.The detection rates of various types of appendicitis were analyzed by CT,ultrasound,Alvarado score and combined analysis,in order to explore the diagnostic value of Alvarado score,CT and ultrasound in children with acute appendicitis.124 children with fecal stone appendicitis(mean 6.71 + 3.31 years old,78 males and 46 females)who underwent CT examination were analyzed.All CT images of children with fecal appendicitis were reconstructed by MPR,and the long and short diameters of fecal stones were measured on cross-sectional,coronal or sagittal planes.The vertical distance between the fecal stone and the outer edge of the right rectus abdominis was measured on the cross-section(the fecal stone was negative on the outer edge of the right rectus abdominis and positive on the inner edge of the outer edge of the right rectus abdominis).The corresponding vertebral level was measured on the coronal plane: the lower edge of the upper vertebral body to the lower edge of the body was the same vertebral level,and then the same vertebral level was divided into upper 1/3,middle 1/3 and lower 1/3.According to the measured data,using statistical software,the vertical distance between the fecal stones and the outer edge of the right rectus abdominis muscle was taken as the transverse axis,and the corresponding vertebral level was taken as the longitudinal axis.The plane distribution map of the fecal stones,i.e.the projection distribution of the fecal stones on the body surface was made.ResultsIn this study,among 397 children with acute appendicitis diagnosed preoperatively,18(5 ileocecal diverticula,3 other Meckel diverticula,3 intussusception,3 colon perforation,1 ascending colitis,1 cecumitis and 2 mesenteric lymphadenitis)were confirmed as acute appendicitis,with an average age of 6.9 ± 3.49 years and 245 males(64.6%).Among them,185 cases(173 cases of acute appendicitis confirmed by pathology and 12 cases of non-acute appendicitis)underwent CT and ultrasonography simultaneously.Chi-square test showed that there was no significant difference in sex between appendicitis group and non-appendicitis group.T-test showed that there was no significant difference in average age,average white blood cell count,average percentage of neutrophils and average CRP between appendicitis group and non-appendicitis group(P > 0.05),but the Alvarado score of appendicitis group was significantly higher than that of non-appendicitis group,and there was significant difference between them(P = 0.001).The sensitivity and specificity of CT in the diagnosis of acute appendicitis in children were 96.0% and 58.3% respectively;the sensitivity and specificity of Alvarado score(> 7)in the diagnosis of acute appendicitis in children were 65.3% and 66.7% respectively;the sensitivity and specificity of ultrasound in the diagnosis of acute appendicitis in children were 90.1% and 50% respectively;the sensitivity and specificity of Alvarado score combined with CT in the diagnosis of acute appendicitis in children were respectively.98.8% and 41.7%.The sensitivity was significantly higher than that of Alvarado score alone in the diagnosis of acute appendix.The sensitivity and specificity of Alvarado score combined with ultrasonography in the diagnosis of acute appendicitis in children were 96.5% and 33.3%,respectively.The sensitivity of Alvarado score was significantly higher than that of Alvarado score alone in the diagnosis of acute appendicitis.Mcnemar test was used to compare the sensitivity of the two methods: Alvarado score was used to diagnose children's acute appendicitis alone,and CT and Alvarado score were used to diagnose children's acute appendicitis together(P < 0.05).Alvarado score was also used to diagnose children's acute appendicitis separately,and Alvarado score was used to diagnose children's acute appendicitis jointly(P < 0.05).The sensitivity,specificity and accuracy of CT in diagnosing acute appendicitis in children were 86.7%,66.6% and 83.3%,respectively,compared with that of ultrasound alone(P=0.052).Positive predictive value and negative predictive value were 92.9% and 50%,respectively;sensitivity,specificity and accuracy of CT in Alvarado score 5-6 were 91.4%,55.6%,86.6%,positive predictive value and negative predictive value were 93.0% and 50%,respectively;sensitivity,specificity and accuracy of CT in Alvarado score 5-6 were 98%,66.6%,97.1%,positive predictive value and negative predictive value were 99%,respectively.50%.According to the pathological results,173 cases of acute appendicitis were divided into four groups: simple appendicitis(13 cases),purulent appendicitis(95 cases),gangrenous appendicitis(37 cases),periappendiceal abscess(28 cases).CT has higher sensitivity than ultrasound in the diagnosis of various pathological types of appendicitis in children,especially gangrenous appendicitis.Among 144 children with appendiceal fecalith,the detection rate of appendiceal fecalith by CT(86.1%)was significantly higher than that by US(62.5%)and P < 0.05.According to the statistical data of appendiceal fecalith's long and short diameter,we defined appendiceal fecalith's long/short diameter >1.5 as long strip fecal stone,and appendiceal fecalith's long/short diameter < 1.5 as round fecal stone,The results showed that there were 79 cases(63.7%)of long strip dung stone and 45 cases(36.3%)of circular fecalith,including 2 cases of ring fecalith.In our 124 cases of appendicitis with fecalith,all the appendiceal fecalith were located in the right abdomen,the right side of umbilical horizontal line.According to the plane distribution of appendiceal fecalith,we used the horizontal line of L4 lower margin as X-axis and the outer margin of right rectus abdominis as Y-axis.Among the four quadrants,9(7%)were in the first quadrant and the second quadrant,27(21.8%)in the third quadrant and 88(71.0%)in the fourth quadrant.Conclusions1.The combination of Alvarado score and CT or ultrasound improves the diagnostic value of predicting acute appendicitis in children,especially in patients with low and middle Alvarado score.CT combined with Alvarado score is more sensitive than US combined with Alvarado score in the diagnosis of appendicitis in children.2.CT is more sensitive than ultrasound in the diagnosis of appendicitis in children,especially for gangrenous appendicitis.CT is more sensitive than ultrasound in the diagnosis of appendiceal fecalith.3.In the surface projection of appendiceal fecalith,the horizontal line of L4 lower margin is used as the transverse axis,and the outer margin of right rectus abdominis is used as the longitudinal axis.The appendiceal fecalith mainly concentrate in the fourth quadrant. |
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