The Association Between C-Reactive Protein Levels and Pediatric Appendicitis Score and the Severity of Appendicitis in Children.

BACKGROUND: Acute appendicitis is a common cause of abdominal pain leading to emergent abdominal surgery in children. C-reactive protein (CRP), an inflammatory marker typically elevated in acute appendicitis, and Pediatric Appendicitis Score (PAS), a clinical scoring system used for the diagnosis of appendicitis, have the potential to predict the severity of inflammation of the appendix. This may be useful in helping the physician make a treatment plan prior to surgery. OBJECTIVE: The purpose of this study was to assess whether CRP value and PAS differ with the extent of inflammation of the appendix seen on histologic examination. METHODS: This was a prospective observational study of patients diagnosed with acute appendicitis via computed tomography or ultrasound. Enrolled patients had CRP levels drawn, PAS calculated, and appendix pathology reviewed. Appendix pathology was categorized by the pathologist on the basis of the level of inflammation: simple, suppurative, gangrenous, and perforated. RESULTS: One hundred sixty-three patients were enrolled. CRP levels and PAS were statistically different (p < 0.002) among the four pathology classifications. Patients with simple appendicitis (n = 3) had a mean CRP of 2.95 mg/L and PAS of 3.9, patients with suppurative appendicitis (n = 99) had a mean CRP of 26.89 mg/L and PAS of 6.5, patients with gangrenous appendicitis (n = 56) had a mean CRP of 91.11 mg/L and PAS of 7.5, and patients with perforated appendicitis (n = 6) had a mean CRP of 154.17 mg/L and PAS of 7. The results remained statistically significant (p < 0.002) after adjusting for age, race, and sex. When combined-PAS ≥ 8 and CRP level > 40 mg/L-the specificity of complicated appendicitis was 91.2% and positive predictive value was 72.7%. CONCLUSIONS: Higher CRP levels and PAS were associated with increased histologic inflammation of the appendix. This study provides preliminary evidence that CRP and PAS could potentially assist in treatment decisions for appendicitis.

Impact of In-Hospital Timing to Appendectomy on Perforation Rates in Children with Appendicitis.

BACKGROUND: There is controversy regarding whether in-hospital time delay to appendectomy in children with appendicitis affects risk for perforation. OBJECTIVE: Our aim was to evaluate the impact of time delay from emergency department (ED) presentation to operating room (OR) appendectomy on rates of developing appendiceal perforation in children who present with computed tomography (CT)-confirmed, uncomplicated (no radiographic evidence of perforation) appendicitis. METHODS: We conducted a retrospective case review of 248 consecutive children aged ≤18 years with CT-confirmed uncomplicated appendicitis during a 4-year period. RESULTS: There were 149 males and 99 females, all received subsequent appendectomy. Despite all receiving ED parenteral antibiotic therapy, 54 (22%) developed in-hospital appendiceal perforation (surgeon operative observation or pathologist histologic analysis). No patient developed perforation when appendectomy was performed within 9 h after ED presentation; the rate of perforation was approximately sixfold greater in those with in-hospital delay >9 h (25%) vs. ≤9 h (4.6%). The rate of developing perforation increased to 21% during hours 9-24, and 41% after 24 h. Regression analysis showed three factors were significantly associated with developing perforation: longer mean time delay from ED presentation to OR appendectomy, presence of fever, and presence of an appendicolith. The risk for developing perforation increased by 1.10 for each hour of time delay from ED presentation to OR appendectomy; the estimated odds ratios for developing perforation per interval of in-hospital delay were 2.05 at 8 h, 4.22 at 16 h, and 8.67 at 24 h. CONCLUSIONS: Increasing in-hospital time delay from ED presentation to OR appendectomy is associated with increased risk for developing appendiceal perforation in children who present with CT-documented uncomplicated appendicitis. Risk is approximately sixfold greater in those who experience delay >9 h vs. those whose delay is ≤9 h. Antibiotic therapy does not reliably prevent progression of the disease. Appendectomy should be considered an urgent procedure to maximize outcomes and prevent complications associated with appendix perforation.