Original Scientific Paper Eur Surg (2008) 40/1: 27–29 DOI 10.1007/s10353-007-0376-7 # Springer-Verlag 2008
Appendicoliths and appendectomy in the pediatric population K. Paya1 , C. Treitl1 , A. Barousch2 , J. Wurm3 , R. Felder-Puig4 , and S. Puig5 1
Department of Surgery, Medical University of Vienna, Vienna, Austria Department of Medical Chemistry, Medical University of Vienna, Vienna, Austria 3 Department of Pediatric Surgery, Landes-Frauen- und Kinderklinik, Linz, Austria 4 St. Anna Children’s Hospital, Vienna, Austria 5 Research Program for Evidence based Medical Diagnostics, Paracelsus Private University Salzburg, Salzburg, Austria 2
Received June 16, 2007; accepted October after revision November 28, 2007 # Springer-Verlag 2008
Kotsteine und Appendektomie im Kindesalter Zusammenfassung. Grundlagen: Kotsteine der Appendix sind eine bekannte Ursache fu¨r die Appendizitis. Das Vorhandensein eines Appendikolithen per se ko¨nnte daher eine Indikation zur Appendektomie darstellen. Methodik: Retrospektive Untersuchung u¨ber einen Zeitraum von 6 Jahren aller Blinddarmoperationen. Verlauf und Diagnose wurden in Bezug auf das Vorhandensein eines Appendikolithen fu¨r verschiedene pa¨diatrische Altersgruppen erhoben. Diese wurden in folgende Gruppen eingeteilt: 0–4 Jahre, 4–6 Jahre, 6–10 Jahre, 10–14 Jahre, 14–18 Jahre, sowie 3 Kategorien (keine Blinddarmentzu¨ndung, Blinddarmentzu¨ndung, Perforation) zugeordnet. Ergebnisse: Neunhundertneunzig Patienten waren inkludiert. Die Inzidenz eines Appendikolithen betrug 28,6%, bei 4– 6ja¨hrigen 37,6%. Appendikolithen fu¨hrten signifikant ha¨ufiger zur Perforation (odds ratio 2,27; p < 0,0001), in den Altersgruppen 0–6 Jahre vs 6–18 Jahre betrug die odds ratio: 10,2; (p< 0,0001). Der pra¨operative Krankheitsverlauf ist signifikant ha¨nger in der Gruppe ohne Appendikolith (p ¼ 0,04). Schlussfolgerungen: Appendikolithen sind ein hoch signifikanter Faktor fu¨r das Auftreten einer spontanen Perforation. Das rechtfertigt die Appendektomie zur Vermeidung der Perforation bei zufa¨llig entdecktem Appendikolith. Schlu¨sselwo¨rter: Appendizitis, Fa¨kolith, Appendikolith, Kotstein, Perforation. Summary. Background: Improved diagnostic techniques increase the number of incidental findings of appenCorrespondence: Kurosh Paya, M.D., Department of Surgery, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria. Fax: þþ43-1-40400 6832 E-mail:
[email protected]
dicoliths even without any patient complaints. Appendicoliths are one cause for appendicitis, and seem to justify elective appendectomy. Methods: Retrospective evaluation of all patients who underwent appendectomy within a period of 6 years. Stratification into 5 groups: 0–4, 4–6, 6–10, 10–14 and 14–18 years and categorization into 3 possible outcomes: no appendicitis, appendicitis, perforated appendicitis. Results: Nine hundred and ninety patients were included. The incidence of appendicoliths was 28.6%, rising to 37.6% in preschool children. Appendicoliths were strongly associated with appendiceal rupture (odds ratio totally: 2.27; p < 0.0001; age group 0–6 years vs 6–18 years odds ratio: 10.2; p< 0.0001). Preoperative history was significantly higher in patients without appendicolith (p ¼ 0.04). Conclusions: Appendicoliths are significantly associated with spontaneous perforation. Therefore elective appendectomy in the presence of an appendicolith is justified to avoid perforation. Key words: Appendicitis, feacolith, appendicolith, perforation.
Introduction Appendicoliths are thought to be a cause and one of several predictive signs of appendicitis [1–3]. They are a common finding in appendicitis, particularly in cases of perforation [4, 5]. Perforation is the worst outcome with high morbidity and possible mortality, and therefore it should be avoided by performing early appendectomy [6]. Rates of perforation are particularly high in children below the age of 6 years [4, 7]. Patients in this age group usually present with rather unspecific symptoms in case of appendicitis unless perforation occurs, and therefore diagnosis often is delayed. The use of radiological diagnostic tools like ultrasound and CT makes the detection of appendicoliths easier and more frequent [8]. Therefore,
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K. Paya et al.: Appendicoliths and appendectomy
early (even elective) appendectomy to avoid imminent appendicitis is repeatedly discussed, particularly as minimally invasive techniques are now being increasingly applied [9, 10].
Material and methods We retrospectively evaluated the records of all patients who underwent appendectomy at our department over a period of 6 years. The presence of an appendicolith was confirmed by histopathological examination of the specimen in all cases and additional macroscopic abdominal search undertaken in cases of perforation. We compared patients’ characteristics, history, laboratory data and outcome with regard to the presence or absence of an appendicolith. Collected data included history of pain and other complaints, clinical examination, white blood cell count and CRP (C-reactive protein). Statistical analyses were performed using SAS (Statistical Analysis Systems Inc.). For group comparisons, we used contingency tables and chi-square tests. A p-value of 0.05 was determined to provide statistical significance. Frequencies including 95% confidence intervals (95%CI) were calculated.
Results Nine hundred and ninety patients aged between 3 days and 19 years (average age: 10 years 4 years standard deviation) had undergone appendectomy. 540 (54.5%) were boys, 450 (45.5%) girls (ratio male: female ¼ 1.2:1). The diagnosis appendicitis was confirmed by histology in 733 appendectomies (73.9%). Two hundred and fiftyseven patients (26.1%) showed no evidence of inflammation in their appendix and had received a so-called negative appendectomy. Two hundred and eighty-three patients (28.6%) presented with a faecolith in their appendix while 707 (71.4%) did not. 76.2% of all patients presenting with an appendicolith also had histologically proven appendicitis. Laboratory
Table 1. History of abdominal pain and recurrent visits to a physician Appendicolith Appendicolith present not present Abdominal pain episodes in history since One week 207 (75.3%) One week to one month 18 (6.5%) > One month to several years 50 (18.2%) Frequency missing or unclear 8 Recurrent visits to a physicians Yes No Frequency missing or unclear
for abdominal 92 (37.1%) 156 (62.9%) 35
505 (74.7%) 31 (4.6%) 140 (20.7%) 31 pain episodes 272 (44.8%) 335 (55.2%) 100
data were statistically similar in both groups (with=without appendicolith) for inflammation parameters (mean leucocyte count: 14500 vs 13665=mm3; mean CRP: 5.2 vs 4.4 g=dl). Figure 1 displays frequency of the 3 outcome groups (perforated appendicitis, appendicitis, no appendicitis) with the presence or absence of an appendicolith. Rate of perforated appendicitis was nearly twice in the group positive for an appendicolith (29.3%, 95%CI 26.6%; 32.0%) compared to the group negative for an appendicolith (15.6%, 95%CI 13.4%; 17.8%). Risk ratio and odds ratio for perforation in the presence of appendicoliths were 1.72 and 2.27, respectively. Table 1 displays previous episodes of abdominal pain and of recurrent physician visits for such episodes with regard to the presence or absence of an appendicolith. Patients in the appendicolith-positive group were significantly less likely for episodes of abdominal pain and to suffer from recurrent physician visits in their history than patients in the appendicolith-negative group (37.1% vs. 44.8%, p ¼ 0.04). Faecolithes were found in 83=193 perforated appendices (43.0%, 95%CI 36.0%; 50.0%), in 133=540 non-perforated appendices (24.6%, 95%CI 21.0%; 28.2%) and in 67=257 patients without appendicitis (26.1%, 95%CI 20.7%; 31.5%) (p < 0.0001). Splitting up the age groups, the highest proportion of appendicoliths was seen in 4–6 year-old children (37.6%). This was also the age group with the highest incidence of perforation (43.5%). Altogether, the prevalence of perforation in the presence of an appendicolith was significantly higher in children aged 0–6 years (59.2%) than in patients aged >6–18 years (23.1%; p < 0.001; odds ratio: 10.2, 95%CI 4.7; 22.2).
Discussion
Fig. 1. Distribution of patients with=without appendicolith related to the pathohistological status of the appendix
Appendicoliths are hard concretions consisting of stool, which are present in a considerably high proportion of appendices resected because of true or suspected appendicitis (up to 52%) [5, 11–13] and a significant factor associated with pediatric appendicitis [4, 9]. The pathophysiological pathway has been shown as luminal obstruction leading to decreased local circulation followed by mucosal lesions and finally infection [1]. Based on these findings, true appendicitis is expected significantly more often in appendectomies when an appendicolith is found
K. Paya et al.: Appendicoliths and appendectomy
whereas so-called negative appendectomies should be significantly lower [13]. This hypothesis could be confirmed in our sample. With the more frequent use of new radiological techniques for abdominal imaging, appendicoliths are detected more often by chance without radiological signs of appendiceal inflammation [14]. In these cases, faecoliths are sometimes even the most specific finding [3]. This raises the question whether any indication is given even for elective appendectomy when we find an appendicolith in a patient with low clinical suspicion of appendicitis. A few publications have evaluated the prevalence of appendicoliths with or without appendicitis and have also drawn different conclusions [5, 11, 15, 16]. However, most of these contributions deal with adult patients, not considering that the highest prevalence of appendicitis is at the age of 10–14 years [17]. In addition, at preschool age, an age in which appendicitis occurs rarely, appendicoliths seem not only to be the most frequent cause but also to accelerate development of appendiceal rupture. This age group had a significantly increased risk for perforation in the presence of an appendicolith. These high perforation rates are well known [4, 7], but have not up to now been able to be explained. It seems to be obvious that the high prevalence of appendicolithes at this age is one of the factors responsible for the increased perforation rate. The answer to our question may become easier knowing that perforation in appendicitis increases postoperative morbidity up to 59% [6, 18] and delay in treatment is the most predictive sign of perforation [4]. Taken together, our data give evidence that appendicoliths lead to a two-fold risk of appendiceal perforation in pediatric patients and a six-fold risk in patients up to 6 years of age. They seem to accelerate the development of appendicitis and subsequent perforation. Based on these findings, elective appendectomy in cases of radiological detected appendicoliths, particularly in preschool children even with otherwise unspecific symptoms of appendicitis seems to be justified to avoid perforation. However, a limitation of our study is the retrospective design.
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