<< An Evidence-Based Review Of Acute Appendicitis In Childhood


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Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.

To help the reader judge the strength of each reference, pertinent information about the study, such as the type of study and the number of patients in the study will be included in bold type following the reference, where available.

  1. Reynolds SL, Jaffe DM. Diagnosing abdominal pain in a pediatric emergency department. Pediatr Emerg Care. 1992;8:126-128. (Prospective; 377 patients)
  2. Scholer S, Pituch K, Orr D, et al. Clinical outcomes of children with acute abdominal pain. Pediatrics. 1996;98:680-685. (Retrospective; 1141 patients)
  3. Guthery SL, Hutchings C, Dean JM, et al. National estimates of hospital utilization by children with gastrointestinal disorders: analysis of the 1997 kids’ inpatient database. J Pediatr. 2004;144:589-594.(Retrospective; 1.9 million patients)
  4. Reynolds SL, Jaffe DM. Children with abdominal pain in the pediatric emergency department. Pediatr Emerg Care. 1990;6(1):8-12. (Retrospective; 371 patients)
  5. O’Shea JS, Bishop ME, Alario AJ, et al. Diagnosing appendicitis in children with acute abdominal pain. Pediatr Emerg Care. 1988;4(3):172-176. (Prospective; 246 patients)
  6. Alloo J, Gerstle T, Shilyansky J, et al. Appendicitis in children less than 3 years of age: a 28-year review. Ped Surg Int. 2004;19:777-779. (Retrospective; 27 patients)
  7. Nance ML, Adamson WT, Hedrick HL. Appendicitis in the young child: a continuing diagnostic challenge. Pediatr Emerg Care. 2000;16:160-162. (Retrospective; 132 patients)
  8. Cappendijk VC, Hazebroek FW. The impact of diagnostic delay in the course of acute appendicitis. Arch Dis Child 2000;83:64-66. (Retrospective; 129 patients)
  9. Rappaport WD, Peterson M, Stanton C. Factors responsible for high perforation rate seen in early childhood appendicitis. Am Surg. 1989;55(10):602-605. (Retrospective; 77 patients)
  10. Addiss DG, Shaffer N, Fowler BS, et al. The epidemiology of appendicitis and appendectomy in the United States. Am J Epidemiol. 1990;132:910-925. (Retrospective; database)
  11. Luckmann R, Davis P. The epidemiology of acute appendicitis in California: Racial, gender and seasonal variation. Epidemiology. 1991;2(5):323-330. (Retrospective; database).
  12. Aarabi S, Sidhwa F, Riehle KJ, et al. Pediatric appendicitis in New England: epidemiology and outcomes. J Pediatr Surg. 2011;46:1106-1114. (Retrospective; 2,878,324)
  13. Janik JS, Firor HV. Pediatric appendicitis: a 20-year study of 1640 children in Cook County (Illinois) Hospital. Arch Surg. 1979;114(6):717-719. (Retrospective; 640 patients)
  14. Owings MF, Kozak LJ. Ambulatory and inpatient procedures in the United States, 1996. Vital Health Stat 13. 1998; 139:1- 119. (National Vital Health Statistics)
  15. Rothrock S, Pagane J. Acute appendicitis in children: emergency department diagnosis and management. Ann Emer Med. 2000;36:39-51. (Review)
  16. Rothrock S, Skeoch G, Rush J. Clinical features of misdiagnosed appendicitis in children. Ann Emer Med. 1991;20:45-50. (Retrospective; 181 patients)
  17. Horwitz J, Gursoy M, Jaksic T, et al. Importance of diarrhea as a presenting symptom of appendicitis in very young children. Am J Surg. 1997;173:80-82. (Retrospective; 63 patients)
  18. Buschard K, Kjaeldgaard A. Investigation and analysis of the position, fixation, length and embryology of the veriform appendix. Acta Chir Scand. 1973;139(3):293-298. (Prospective; 292 patients)
  19. Guidry S, Roole G. The anatomy of appendicitis. Am Surg. 1994;60:68-71. (Prospective; 100 patients)
  20. Wagner J, McKinney P, Carpenter J. Does this patient have appendicitis? JAMA. 1996;276:1589-1594. (Review)
  21. Jones B, Demetriades D, Segal I, et al. The prevalence of appendiceal fecaliths in patients with and without appendicitis. Ann Surg. 1985;202:80-82. (Prospective; 136 patients)
  22. Nitecki S, Karmeli R, Sarr MG. Appendiceal calculi and fecaliths as indications for appendectomy. Surg Gynecol Obstet. 1990;171:185-188. (Retrospective; 3397 patients)
  23. Langenscheidt P, Lang C, Puschel W, et al. High rates of appendicectomy in a developing country: an attempt to contribute to a more rational use of surgical resources. Eur J Surg. 1999;165(3):248-252. (Prospective; 165 patients)
  24. Guillet-Caruba C, Cheikhelard A, Guillet M, et al. Bacteriologic epidemiology and empirical treatment of pediatric complicated appendicitis. Diagn Microbiol Infect Dis. 2011;69(4):376-381. (Prospective; 93 patients)
  25. Kanegaye JT, Harley JR. Pneumonia in unexpected locations: an occult cause of pediatric abdominal pain. J Emerg Med. 1995;13(6):77779. (Case series; 3 patients)
  26. Vignault F, Filiatrault D, Brandt ML, et al. Acute appendicitis in children: evaluation with US. Radiology. 1990;176:501-504. (Prospective; 70 patients)
  27. Pfoh E, Wessels MR, Goldmann D, et al. Burden and economic cost of group A streptococcal pharyngitis. Pediatrics. 2008;121(2):229-234. (Prospective; 135 patients)
  28. Samuel M. Pediatric appendicitis score. J Pediatr Surg. 2002;37(6):877-881.
  29. Goldman RD, Carter S, Stephens D, et al. Prospective validation of the pediatric appendicitis score. J Pediatr. 2008;153:278-282.
  30. Alvarado A. A practical score for the early diagnosis of acute appendicitis. Ann Emerg Med. 1986;15(5):557-564.
  31. Hong JJ, Cohn SM, Ekeh AP, et al. A prospective randomized study of clinical assessment versus computed tomography for the diagnosis of acute appendicitis. Surg Infect (Larchmt). 2003;4(3):231-239. (Prospective randomized control; 182 patients)
  32. Liu JL, Wyatt JC, Deeks JJ, et al. Systematic reviews of clinical decision tools for acute abdominal pain. Health Technol Assess. 2006;10(47):1-167, iii-iv. (Electronic database search and review; 32 studies, 27 articles)
  33. Green R, Bulloch B, Kabani A, et al. Early analgesia for children with acute abdominal pain. Pediatrics. 2005;116:978-983. (Prospective randomized controlled; 108 patients)
  34. Bailey B, Bergeron S, Gravel J, et al. Efficacy and impact of intravenous morphine before surgical consultation in children with right lower quadrant pain suggestive of appendicitis: a randomized controlled trial. Ann Emerg Med. 2007;50(4):371-378. (Prospective randomized controlled trial; 90 patients)
  35. Daehlin L. Acute appendicitis during the first three years of life. Acta Chir Scand. 1982;148(3):291-294. (Retrospective; 49 patients)
  36. Barker AP, Davey RB. Appendicitis in the first three years of life. Aust N Z J Surg. 1988;58(6):491-494. (Case series, retrospective)
  37. Bundy DG, Byerley JS, Liles EA, et al. Does this child have appendicitis? JAMA. 2007;298(4):438-451. (Systematic review)
  38. Kharbanda AB, Taylor GA, Fishman SJ, et al. A clinical decision rule to identify children at low risk for appendicitis. Pediatrics. 2005;116(3):709-716. (Prospective; 601 patients)
  39. Kwan KY, Nager AL. Diagnosing pediatric appendicitis: usefulness of laboratory markers. Am J Emerg Med. 2010;28:1009-1015 (Prospective; 209 patients)
  40. Wu HP, Chen CY, Kuo IT, et al. Diagnostic values of a single serum biomarker at different time points compared with Alvarado score and imaging examinations in pediatric appendicitis. [published online ahead of print February 23, 2011.] J Surg Res. doi: 10.1016/j.jss.2011.01.047. (Prospective; 594 patients)
  41. Puylaert JB. Acute appendicitis: US evaluation using graded compression. Radiology. 1986;158(2):355-360. (Prospective; 60 patients)
  42. Doria AS, Moineddin R, Kellenberger CJ, et al. US or CT for diagnosis of appendicitis in children and adults? A meta-analysis. Radiology. 2006;241(1):83-94. (Meta-analysis)
  43. Schuh S, Man C, Cheng A, et al. Predictors of non-diagnostic ultrasound scanning in children with suspected appendicitis. J Pediatr. 2011;158(1):112-118. (Prospective observational; 263 patients)
  44. Garcia-Pena BM, Mandl KD, Kraus SJ, et al. Ultrasonography and limited computed tomography in the diagnosis and management of appendicitis in children. JAMA. 1999;282(11):1041-1046. (Prospective; 139 patients)
  45. Kaiser S, Frenckner B, Jorulf HK. Suspected appendicitis in children: US and CT--a prospective randomized study. Radiology. 2002;223(3):633-638. (Prospective randomized controlled; 600 patients)
  46. Kosloske AM, Love CL, Rohrer JE, et al. The diagnosis of appendicitis in children: outcomes of a strategy based on pediatric surgical evaluation. Pediatrics. 2004;113(1):29-34. (Retrospective; 356 patients)
  47. Lowe LH, Perez R Jr, Scheker LE, et al. Appendicitis and alternate diagnoses in children: findings on unenhanced limited helical CT. Pediatr Radiol. 2001;31(8):569-577 (Review)
  48. Hernanz-Schulman M. CT and US in the diagnosis of appendicitis: an argument for CT. Radiology. 2010;255(1):3-7. (Review)
  49. Sivit CJ, Applegate KE, Stallion A, et al. Imaging evaluation of suspected appendicitis in a pediatric population: effectiveness of sonography versus CT. AJR Am J Roentgenol. 2000;175(4):977-980. (Prospective; 315 patients)
  50. Callahan MJ, Rodriquez DP, Taylor GA. CT of appendicitis in children. Radiology. 2002;224(2):325-332. (Review)
  51. Kharbanda AB, Taylor GA, Bachur RG. Suspected appendicitis in children: rectal and intravenous contrast-enhanced versus intravenous contrast-enhanced CT. Radiology. 2007;243(2):520-526. (Comparative study)
  52. Berdon WE, Slovis TL. Where are we since ALARA and the series of articles on CT dose in children and risk of long term cancers: what has changed? Pediatr Radiol. 2002;32(10):699. (Editorial)
  53. Hall EJ. Lessons we have learned from our children: cancer risks from diagnostic radiology. Pediatr Radiol. 2002;32(10):700-706. (Review)
  54. Brody AS, Frush DP, Huda W, et al. Radiation risk to children from computed tomography. Pediatrics. 2007;120(3);677-682. (Review)
  55. Andersen BR, Kallehave FL, Andersen HK, et al. Antibiotics versus placebo for prevention of postoperative infection after appendicectomy. Cochrane Database Syst Rev. 2005;3:CD001439. (Review)
  56. Horwitz JR, Gursoy M, Jaksic T, et al. Importance of diarrhea as a presenting symptom of appendicitis in very young children. Am J Surg. 1997;173(2):80-82.
  57. Reynolds SL. Missed appendicitis in a pediatric emergency department. Pediatr Emerg Care. 1993;9(1):1-3. (Retrospective; 87 patients)
  58. Murch SH. Diarrhoea, diagnostic delay, and appendicitis. Lancet. 2000;356(9232):787. (Commentary)
  59. Fox JC, Solley M, Anderson CL, et al. Prospective evaluation of emergency physician performed bedside ultrasound to detect acute appendicitis. Eur J Emerg Med. 2008;15(2):80-85. (Prospective; 132 patients)
  60. Wan MJ, Krahn M, Ungar WJ, et al. Acute appendicitis in young children: cost effectiveness of US versus CT in diagnosis – a Markov decision analytic model. Radiology. 2009;250(2):378-386.
  61. Hagendorf BA, Clarke JR, Burd RS. The optimal initial management of children with suspected appendicitis: a decision analysis. J Pediatr Surg. 2004;39(6):880-885. (Retrospective; 117 patients)
  62. Rao PM, Rhea JT, Novelline RA, et al. Effect of computed tomography of the appendix on treatment of patients and use of hospital resources. New Engl J Med. 1998;338(3):141-146. (Retrospective; 100 patients)
  63. Pena BM, Taylor GA, Lund DP, et al. Effect of computed tomography on patient management and costs in children with suspected appendicitis. Pediatrics. 1999;104(3):440-446. (Retrospective; 609 patients)
  64. Bratton SL, Haberkern CM, Waldhausen JH. Acute appendicitis risks of complications: age and Medicaid insurance. Pediatrics. 2000;106:75-78. (Retrospective; 13,532 patients)
Publication Information

Inna Elikashvili; Lou Spina

Publication Date

March 1, 2012

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