Ann Surg Treat Res.  2023 Jan;104(1):51-59. 10.4174/astr.2023.104.1.51.

Clinical course in children with equivocal appendicitis on computed tomography: a retrospective cohort study

• Yang HB
• Song HB
• Han JW
• Youn JK
• Ko D
• Ryu YJ
• Kim JY
• Kim HY

• KMID: 2537630
• DOI: http://doi.org/10.4174/astr.2023.104.1.51

Abstract

Purpose
Appendectomy is one of the most common surgeries in children. Although various radiological examinations are performed, they do not always reveal a definitive diagnosis of appendicitis. This study aimed to investigate the clinical course of equivocal appendicitis, identify the factors associated with appendectomy, and suggest appropriate management for these patients.
Methods
Patients younger than 19 years who visited Seoul National University Bundang Hospital with a differential diagnosis of appendicitis from January 2013 to December 2017 were included. All participants conducted ‘appendiceal CT’ with a scoring scale of 1–5. The higher the score, the higher the likelihood of a radiologic diagnosis of appendicitis. We defined the appendicitis CT score of 2–4 as equivocal appendicitis (n = 143). Medical records were reviewed retrospectively for demographics, further examination as abdominal ultrasonography, and appendectomy status (yes or no). The mean follow-up period was 15.6 ± 71 days.
Results
Equivocal appendicitis accounted for 16.7%. Additional ultrasonography test was performed in 24.5% (35 of 143). In total, 34 patients (23.8%) underwent appendectomy. Among the patients with appendiceal CT scores 2, 3, and 4, 4.9%, 50.0%, and 87.5% underwent appendectomy, respectively. Higher WBC count, higher appendicitis CT score, and readmission were significantly associated with appendectomy in patients with equivocal appendicitis.
Conclusion
Higher appendicitis CT score and WBC level were positively associated with appendectomy. Careful observation can be a treatment option in appendicitis CT score 2 or 3 groups. Appendectomy is the first-line treatment for patients with appendicitis score 4. Additional ultrasonography test is advisable to determine treatment modality for equivocal appendicitis.

Keyword

Appendectomy; Appendicitis; Computed tomography; Pediatrics; Surgery

Figure

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  Fig. 1 Patient collection. Patients with appendicitis CT scores of 2 to 4 were enrolled in the study. R/O, rule out. a)Enterocolitis, 24; ovary cyst, 8; urinary abnormality, 6; ileus, 6; diverticulitis, 3; pancreatitis, 2; superior mesenteric artery syndrome, 2; upper gastrointestinal perforation, 2; intussusception, 2; omental infarction, 2; intestinal duplication, 1; hepatitis, 1; pancreatitis, 1; Meckel’s diverticulitis, 1; juvenile polyp, 1; foreign body, 1; solid pseudopapillary tumor, 1; uterine myoma, 1; psoas myositis, 1; empyema, 1.

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  Fig. 2 Appendiceal CT report format. a)In cases with phlegmon or abscess, grade 2 was assigned if there was clear continuity between the lesion and the remaining appendiceal base, indicating that the lesion had originated from the appendix. b)Based on findings of extraluminal gas or appendicolith, periappendiceal fluid or phlegm on, severe periappendiceal fat stranding, and defect in the appendiceal wall.

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  Fig. 3 Examples of appendiceal CT images of equivocal appendicitis (arrows). (A) Score 2, (B) score 3, and (C) score 4.

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  Fig. 4 Clinical course of patients with equivocal appendicitis. SNUBH, Seoul National University Bundang Hospital.

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  Fig. 5 Clinical course of patients with appendicitis CT score 2.

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  Fig. 6 Clinical course of patients with appendicitis CT score 3. SNUBH, Seoul National University Bundang Hospital.

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  Fig. 7 Clinical course of patients with appendicitis CT score 4. SNUBH, Seoul National University Bundang Hospital.

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