Çocukluk Çağı Apandisit Tanısında Ultrasonografi ve Laboratuar Bulgularının Değerlendirilmesi

Amaç: Akut apandisit pediatrik yaş grubunda sık karşılaşılan acil cerrahi durumlardan biridir. Bu çalışmada, pediatrik olgularda akut apandisit tanısında batın ultrasonografi ve laboratuar bulguları retrospektif olarak karşılaştırılmıştır. Gereç-Yöntem: Ocak 2007 - Ocak 2009 tarihleri arasında akut apandisit ön tanısı ile apendektomi yapılan 53’ü kız (%45,5), 61’i erkek (%53,5) toplam 114 olgunun (yaş ortalaması;132 ay) operasyon öncesi ultrasonografi ve laboratuvar bulguları retrospektif olarak değerlendirilmiştir. US’de apendiksin izlenebildiği olgularda; dıştan dışa ölçülen apendiks çapı altı milimetre ve üstündeki değerler patolojik olarak kabul edilmiştir. Ayrıca periapendiküler sıvı ve lenf nodu varlığı, CRP, beyaz küre sayısı, nötrofil yüzdesi patoloji sonuçları ile karşılaştırıldı. Histopatolojik tanı altın standart olarak alındı. Bulgular: Ultrasonografi incelemede 74 hastada apendiks izlenebilmiştir. Apendiks çapı 6 mm ve üstünde anormal olarak yorumlandığında US tanısal duyarlılığı %76,40, özgüllük %80, pozitif öngörü değeri %93,15, negatif öngörü değeri %87,35, doğruluk ise %71,19 olarak bulunmuştur. Apendiks çapı 7 mm ve üstü anormal kabul edildiğinde ise duyarlılık %66,29, özgüllük 88, pozitif öngörü değeri %95,12, negatif öngörü değeri %42,31, doğruluk ise %71,05 olarak bulunmuştur. Beyaz küre sayısı, nötrofil yüzdesi ve CRP düzeyleri akut apandisit olarak değerlendirilen olgularda yüksek olup her iki grup arasında istatistiksel anlamlı farklılık bulunmuştur. Histopatolojik olarak akut apandisit tanısı alan olgular ile normal değerlendirilenlerin US incelemede serbest sıvı ve lenfadenopati saptanan ve saptanmayan olgular arasında istatistiksel anlamlı fark bulunmamıştır (p>0.05). Yöntem: Ultrasonografi uygulama kolaylığı, iyonize radyasyon içermemesi, intravenöz ve oral kontrasta ihtiyaç duyulmaması, ucuz olması ve erişkine göre daha başarılı olması nedeniyle bu hastaların değerlendirilmesinde ilk basamak yöntem olmalıdır. Ultrasonografi apendiks açısından tanısal değil ise, tanısal yöntem olarak ikinci basamakta beyin tomografisi tercih edilmelidir.

Anahtar Kelimeler:

Akut apandisit, ultrasonografi, çocuk, laboratuar bulguları

The Role of Ultrasound and Laboratory Findings for Diagnosis of Appendicitis in Pediatric Patients

Purpose: Acute appendicitis is one of the most common reasons of abdominal surgery in children. The aim of this study was to compare findings of abdomen ultrasonography and laboratory results on the diagnosis of appendicitis in pediatric patients. Materials-Methods: Preopperative ultrasonography and laboratory findings of 114 children (53 girls and 61 boys; mean age: 132 months) who clinically suspected acute appendicitis and undergone appendectomy between January 2007- January 2009 were evaluated retrospectively. If appendix was visualize on US, outer diameter was measured. Six mm or more of outer appendiceal diameter was accepted as a sign of acute appendisicitis. Also periappendicular fluid, lymph node, C-reactive protein (CRP) values, white blood cells and neutrophil percentage were compared with pathologic results. The pathologic diagnosis was the gold standart. Results: Six mm or more of appendiceal diamater was accepted as a sign of acute appendicitis, the corresponding sensitivity, specificity, positive and negative predictive values and accuracy were found 76.40%, 80%, 93.15%, 87.35% and 71.19 % respectively. If 7mm or more of appendiceal diamater accepted as a sign of acute appendicitis, the sensitivity, specificity, positive and negative predictive values and accuracy were found 66.29%, 88% , 95.12%, 42.31% and 71.05% respectively. In patients with acute appendicitis, white blood cells, neutrophil percentage and CRP values were found higher than other patients. There was a significant difference in the white blood cells, neutrophil percentage and CRP values between normal patients and patients with acute appendicitis. There was no significant difference in the presence of periappendicular fluid and lymph node on ultrasonography examination between normal patients and patients with acute appendicitis. Conclusion: Ultrasonography is a cheap, practical and noninvasive method, and does not require ionizing radiation and oral or intravenous contrast material. Therefore, ultrasonography should be used the primary imaging modality for pediatric patients. If ultrasonography is non-diagnostic for appendicitis, computed tomography can be prefered as a second imaging modality

Keywords:

Acute Appendicitis, ultrasonography, children, laboratory findings,

PDF

___

Addis DG, Shaffer N, Fowler BS. The Epidemiology of appendicitis and appendectomy in US. Am J Epidemiol. 1990; 132: 910-925.
Henderson J, Goldacre MJ, Fairweather JM, Marcovicth H. Conditions accounting for substantional time spent in hospital in children 1-14 years. Arch Dis Child. 1992; 67(2):83-86.
Goldin A.B, Khanna P, Thapa JA, Garrison MM, Parisi MT. Revised ultrasound criteria for appendicitis in children improve diagnostic accuracy. Pediatr Radiol. 2011; 41(8):993-999.
Coley B.D. Future of pediatric US. Pediatr Radiol. 2011; 41:(Suppl1) :220-227.
Dallman PR: In Rudolph AM (ed): Pediatrics, 16th ed. New York, Appleton-Centry-Crofts. 1977;1178.
Wiersma F, Toorenvliet BR, Bloem JL, Allema JH, Holscher HC. US examination of the appendix in children with suspected appendicitis: the additional value of secondary signs. Eur Radiol. 2009; 19(2):455-61.
Klein MD. Clinical aproach to a child with abdominal pain who might have appendicitis. Pediatr Radiol. 2007; 37(1):11-4.
Yu S-H. Kim CB, Park JW, Kim MS, Radosevich DM. Ultrasonography in the diagnosis of appendicitis: evaluation by Meta-analysis. Korean J Radiology. 2005;6(4):267-277.
Orr RK, Porter D, Hartman D. Ultrasonography to evaluate adults for appendicitis: decision making based on meta-analysis and probabilistic reasoning. Acad Emerg Med. 1995; 2(7):644-50.
Doria AS, Moineddin R, Kellenberger CJ, Kellenberger CJ, Epelman M, Beyene J, Schuh S, et all. US or CT for diagnosis of appendicitis in children and adult?A Meta-analysis.Radiology. 2006; 241:8394.
Doria AS. Optimazing the role of imaging appendicitis. Pediatric Radiology.;39 (Suppl 2):144-8.
Kessler N, Cyteval C, Gallix B, Lesnik A,Blayac PM, Pujol J, et. al. Appendicitis: evaluation of sensitivity, specificity, and predictive values of US, Doppler US, and laboratory findings. Radiology. 2004; 230(2):4728.
Chan L, Shin LK, Pai RK, Jeffrey RK. Patologic continuum of acute appendiciti: sonografphic findgins and clinical management implications. Ultarsound Q. 2011; 27(2):71-9.
Kwan KY, Nager AL. Diagnosing pediatric appendicitis: usefulness of laboratory markers. American Journal of Emergency Medicine. 2010; 28(9):1009-1015.
Brökor MEE, van Lieshout EM, van der Elst M, Stassen LP, Schepers T. Discriminating Between Simple and Perforated Appendicitis. Journal of Surgical Resarch. 2011 Oct 14 (Epub ahead of print).
Wang LT. The Use of White Blood Cell Count and Left Shift in the Diagnosis of Appendicitis in Children. Pediatric Emergency Care. 2010; 23(2):69-76.
Hörmann M. Scharitzer M, Stadler A,Pokieser P, Puiq Setc.all. Ultrasound of the appendix in children: is the child too obese? Eur Radiol. 2003; 13(6):14281431.
Hernandez J.A. Swischuk LE, Angel CA, Chung D, Chandler R, Lee S. Imaging of acute appendicitis: US as the primary imaging modality. Pediatr Radiol. 2005; 35 (4): 392-395.
Martin AE, Vollman D, Adler B, Caniano GE. CT scans may not reduce the negative appendectomy rate in children. J Pediatr Surg 2004; 39(6):886-890, discussion.
Bahchur R.G. Hennelly K,Callahan MJ, Bachur R. Advenced Radiologic Imaging for Pediatric Appendicitis, 2005-2009:Trends and Outcomes. The Journal of Pediatrics. 2011(Article in press).
Zakaria O, Sultan AT, Khalil TH, Wahba T. Role of clinical judgment and tissue harmonic imaging ultrasonography in diagnosis of paediatric acute appendicitis. World J Emerg Surg 2011; 6(1):39.