Effects of Timing to Diagnosis and Appendectomy in Pediatric Appendicitis.

OBJECTIVES: Prospectively follow pediatric appendicitis patients to assess outcomes and rates of appendiceal perforations relative to duration of symptomatology and appendectomy timing. METHODS: Data were collected on the duration of symptomatology to diagnosis and from diagnosis to appendectomy. Symptomatology duration was evaluated in 24-hour increments, and diagnosis to appendectomy was evaluated in 3-hour intervals. Appendiceal perforation rates, hospital length of stay (LOS), and operating room (OR) times were evaluated. RESULTS: Data were analyzed on 230 patients. Average age was 9.3 years (±3.2), 93 (40%) were female, and 64 (28%) appendectomies were perforated. Perforations had a mean 10 minutes longer OR time (63 vs 50 minutes, P < 0.001) and a 57% increase in hospital LOS (3 days' interquartile range, 1-5 vs 1 day's interquartile range, 1-3; P < 0.001). From diagnosis to appendectomy, those taken 0 to 3 hours, 4 to 6 hours, or longer than 6 hours after diagnosis had no statistically significant difference in hospital LOS or perforation rates and no clinically significant difference in OR times. Symptomatology greater than 48 hours had hospital LOS 55.7% greater and 4.9 times increased odds for perforation than those 0 to 23 hours (P < 0.05).We found no effect on perforation rates, hospital LOS, or OR time when symptomatology duration was compared independently with timing of surgery. CONCLUSIONS: Pediatric patients with appendicitis presenting with greater than 48 hours of symptomatology had 4.9 times increased odds of perforation and 56% greater hospital LOS than those presenting within 0 to 23 hours. We were unable to demonstrate a difference in perforation rates based on emergency department LOS before surgery.

The Frequency of Postreduction Interventions After Successful Enema Reduction of Intussusception.

OBJECTIVES: The objective was to determine the frequency of postreduction, hospital-level interventions among children with successful reduction of ileocolic intussusception and identify factors that predict the need for such interventions. METHODS: This was a retrospective cross-sectional study of children who underwent successful enema reduction for ileocolic intussusception at a single emergency department. Hospital-level interventions were included if they occurred within 24 hours of reduction and were further classified as either major (recurrence or possible perforation) or minor (imaging for suspected recurrence or administration of parenteral narcotics or antiemetics). Binary logistic regression was used to identify predictors for hospital-level interventions. RESULTS: A total of 464 children underwent enema reduction. The median age was 1.7 years (interquartile range [IQR] = 0.8 to 2.5 years), and 66% were male. A total of 435 (94%) were hospitalized with a median hospital stay of 25 hours (IQR = 19 to 34 hours). Nineteen percent (95% confidence interval [CI] = 15% to 22%) needed postreduction interventions, including 6% (95% CI = 4% to 9%) who required major interventions. The median time to any hospital intervention was 9.9 hours (IQR = 6.3 to 16.4 hours). We identified two independent predictors for hospital-level interventions: duration of symptoms > 24 hours (adjusted odds ratio [OR] = 2.1, 95% CI = 1.3 to 3.4) and location of the intussusception tip at (or proximal to) the hepatic flexure (adjusted OR = 1.9, 95% CI = 1.1 to 3.3); the latter factor was also a predictor of a major intervention. None of the children (95% CI = 0 to 1.0%) had an acute decompensation after an initially successful enema reduction. CONCLUSIONS: Clinical decompensation is rare and recurrence is relatively low after an uncomplicated reduction of ileocolic intussusception. However, one in five children required hospital-level interventions after reduction. Children with the intussusception tip at (or proximal to) the hepatic flexure, and those with symptoms for longer than 24 hours, are more likely to require subsequent interventions. Although outpatient management appears safe after a period of observation, caregivers should be counseled about the risk of ongoing symptoms and recurrence.

Management of the child after enema-reduced intussusception: hospital or home?

BACKGROUND: Standard practice has been to admit children for an observation period after enema-reduced intussusception. However, the utility of such routine practice has not been clearly justified. STUDY OBJECTIVES: The main objective was to determine the rate and timing of recurrent intussusception after successful enema reduction and describe any associated complications. METHODS: The study was a retrospective chart review identifying children with enema-reduced intussusception during a 7-year period from 2002 through 2008. Subjects were children ages 0 to 17 years presenting to the Emergency Department (ED) of a tertiary care, free-standing children's hospital with confirmed and uncomplicated enema-reduced intussusception. RESULTS: During the study period there were 98 children with successful enema reduction of intussusception. There were 10 episodes of recurrence in 7 patients, for an overall recurrence rate of 7.1%. Three patients had two recurrences each, and the remainder had single recurrences. Two patients had early recurrences (<48 h) at 3 and 5 h, for an early recurrence rate of 2.0%. The late recurrence rate (>48 h) was 5.1%. No adverse events were noted in any of the recurrences. CONCLUSIONS: Given the low early recurrence rate for enema-reduced intussusception and the minimal risk of adverse outcomes, ED observation for a 6-h period seems to be a safe alternative to inpatient management. These results support previous work and suggest that these patients can be managed on an outpatient basis.

Intussusception: clinical presentations and imaging characteristics.

OBJECTIVE: The objectives of this study were to determine the prevalence of clinical findings associated with intussusception based on age and to evaluate the test characteristics of the presence of air in the ascending colon on abdominal radiographs and the effectiveness of ultrasound in diagnosing intussusception. METHODS: This was a retrospective cohort study via chart review at a tertiary care center from January 2002 to December 2008. All children, aged 0 to 17 years, were identified with intussusception by International Classification of Diseases, Ninth Revision diagnostic coding. Charts were reviewed for clinical signs and symptoms at presentation, and all diagnostic studies were retrieved. A pediatric radiologist reviewed all films and ultrasounds. RESULTS: A total of 219 patients were identified with intussusception. One hundred thirty-two (60%) of patients were male; 127 (60%) were younger than 1 year (median, 7 months), 59 (27%) were 13 to 35 months (median, 23 months), and 33 (15%) were 3 years or older (median, 5 years). Children younger than 12 months were more likely to present with emesis, irritability, and guaiac-positive or grossly bloody stools compared with children older than 12 months (P < 0.05). In children older than 12 months, abdominal pain was the most common symptom (>96%). Plain films were performed in 192 children, and of these, 163 (85%) had no air present in the ascending colon. Abdominal ultrasound was performed on 63 patients, with 58 (92%) having findings consistent with intussusception. CONCLUSIONS: Abdominal pain is the most common complaint in all ages for children presenting with intussusception. In children younger than 12 months, the strongest clinical predictors are emesis, irritability, and blood in the stool. For diagnosing intussusceptions, radiographs of the abdomen performed well, but ultrasound performed better, diagnosing intussusception in 92% of the cases.

Using appendicitis scores in the pediatric ED.

STUDY OBJECTIVE: The aims of the study were to prospectively evaluate the Alvarado and Samuel (pediatric appendicitis score [PAS]) appendicitis scoring systems in children and determine performance based on sex. METHODS: Children with abdominal pain concerning for appendicitis were recruited. Nine parameters evaluated by the scores were documented before imaging/surgery consultation. Test characteristics were calculated on all patients and by sex. RESULTS: Two hundred eighty-seven patients enrolled; median age was 9.8 years; and 155 (54%) were diagnosed with pathologic examination-confirmed appendicitis. Patients with appendicitis had mean PAS of 7.6, and those without had mean of 5.6 (P < .001). Patients with appendicitis had a mean Alvarado of 7.2, and those without had a mean of 5.2 (P < .001). In appendicitis patients, PAS cutoff of 6 or greater would give 137 correct diagnoses; sensitivity, 88%; specificity, 50%; and positive predictive value (PPV), 67%. An Alvarado cutoff of 7 or greater would give 118 correct diagnoses; sensitivity, 76%; specificity, 72%; and PPV, 76%. Both performed better in males than females. CONCLUSION: Regardless of sex, neither PAS nor Alvarado has adequate predictive values for sole use to diagnose appendicitis.

Brain oxygen utilization is unchanged by hypoglycemia in normal humans: lactate, alanine, and leucine uptake are not sufficient to offset energy deficit.

During hypoglycemia, substrates other than glucose have been suggested to serve as alternate neural fuels. We evaluated brain uptake of endogenously produced lactate, alanine, and leucine at euglycemia and during insulin-induced hypoglycemia in 17 normal subjects. Cross-brain arteriovenous differences for plasma glucose, lactate, alanine, leucine, and oxygen content were quantitated. Cerebral blood flow (CBF) was measured by Fick methodology using N(2)O as the dilution indicator gas. Substrate uptake was measured as the product of CBF and the arteriovenous concentration difference. As arterial glucose concentration fell, cerebral oxygen utilization and CBF remained unchanged. Brain glucose uptake (BGU) decreased from 36.3+/-2.6 to 26.6+/-2.1 micromol.100 g of brain(-1).min(-1) (P<0.001), equivalent to a drop in ATP of 291 micromol.100 g(-1).min(-1). Arterial lactate rose (P<0.001), whereas arterial alanine and leucine fell (P<0.009 and P<0.001, respectively). Brain lactate uptake (BLU) increased from a net release of -1.8+/- 0.6 to a net uptake of 2.5+/-1.2 micromol.100 g(-1).min(-1) (P<0.001), equivalent to an increase in ATP of 74 micromol.100 g(-1).min(-1). Brain leucine uptake decreased from 7.1+/-1.2 to 2.5 +/- 0.5 micromol.100 g(-1).min(-1) (P<0.001), and brain alanine uptake trended downward (P<0.08). We conclude that the ATP generated from the physiological increase in BLU during hypoglycemia accounts for no more than 25% of the brain glucose energy deficit.