title: Diagnosing ruptured appendicitis preoperatively in pediatric patients.
abstract: BACKGROUND
  Over the past decade, pediatric patients with ruptured appendicitis (RA) have been successfully treated with IV antibiotics and an interval appendectomy. Because the treatment of acute appendicitis (AA) and RA in children is now diverging, distinguishing between these two conditions preoperatively is critical.
  
  
  METHODS
  A prospective cohort study was conducted. Clinical data were collected, and the attending surgeon's preoperative diagnosis was recorded. Accuracy of the pediatric surgeon's diagnosis was determined. Univariable and multivariable logistic regression were then used to determine independent clinical predictors of RA. Using the relative beta coefficients of these predictors, a scoring system was constructed to aid in the diagnosis of RA.
  
  
  RESULTS
  Two hundred forty-seven patients were evaluated: 98 AA (40%), 53 RA (21%), and 97 not appendicitis (39%). Median age was 10 years old. The overall accuracy of the pediatric surgeon's preoperative diagnosis was 92%. Sensitivity and specificity for the diagnosis of RA were 96% and 83%, respectively. Multivariable regression analysis identified generalized tenderness on examination, duration of symptoms longer than 48 hours, WBC>19,400 cells/microL, abscess, and fecalith on CT scan as independent predictors for RA. A novel scoring system was developed with these variables, and, when applied to the study population, the specificity for the diagnosis of RA improved to 98%.
  
  
  CONCLUSIONS
  Pediatric surgeons differentiate AA from RA and not appendicitis preoperatively with high accuracy and sensitivity, but the specificity for diagnosing ruptured appendicitis is lower. The scoring system improved the specificity of the preoperative diagnosis. The validity and utility of this scoring system should be examined in future studies in larger patient populations.
authors.affiliation: Division of Pediatric Surgery, University of Tennessee Health Science Center, Memphis, TN 38111, USA.
authors.forename: Regan F
authors.initials: RF
authors.lastname: Williams
authors.forename: Martin L
authors.initials: ML
authors.lastname: Blakely
authors.forename: Peter E
authors.initials: PE
authors.lastname: Fischer
authors.forename: Christian J
authors.initials: CJ
authors.lastname: Streck
authors.forename: Melvin S
authors.initials: MS
authors.lastname: Dassinger
authors.forename: Himesh
authors.initials: H
authors.lastname: Gupta
authors.forename: Elizabeth J
authors.initials: EJ
authors.lastname: Renaud
authors.forename: James W
authors.initials: JW
authors.lastname: Eubanks
authors.forename: Eunice Y
authors.initials: EY
authors.lastname: Huang
authors.forename: S Douglas
authors.initials: SD
authors.lastname: Hixson
authors.forename: Max R
authors.initials: MR
authors.lastname: Langham
mesh_terms: D000293:Adolescent; D000465:Algorithms; D000900:Anti-Bacterial Agents / Q000008:administration & dosage; D001062:Appendectomy; D001064:Appendicitis / Q000175:diagnosis* / Q000188:drug therapy / Q000601:surgery; D002648:Child; D002675:Child, Preschool; D003131:Combined Modality Therapy; D005260:Female; D006801:Humans; D016015:Logistic Models; D008297:Male; D015999:Multivariate Analysis; D011446:Prospective Studies; D012680:Sensitivity and Specificity; D014057:Tomography, X-Ray Computed
chemical_list: D000900:Anti-Bacterial Agents