ALVARADO SCORE IN CHILDREN WITH DIAGNOSIS OF ACUTE APPENDICITIS
Autori:
Anko Antabak, Matea Berović, Sven Seiwerth, Dino Papeš, Krešimir Bulić, Marko Bogović, Tomislav Luetić, Stanko Ćavar, Goran Augustin
Sažetak
Alvaradov sustav bodovanja osmišljen je radi smanjenja broja negativnih apendektomija. Rabi se u adultnoj i pedijatrijskoj populaciji, a broj negativnih apendektomija rijetko je manji od 10%. Kako bismo provjerili pouzdanost metode, analizirali smo korelaciju Alvaradova sustava bodovanja i histološke dijagnoze djece apendektomirane zbog sumnje na akutnu upalu crvuljka. U retrospektivnoj studiji obuhvaćeno je 330-ero djece (Zavod za dječju kirurgiju, KBC Zagreb), u razdoblju od siječnja 2014. do prosinca 2016. s kliničkom dijagnozom akutne upale crvuljka. Uključena su sva djeca neovisno o metodi apendektomije. Zbog nepotpune medicinske dokumentacije isključeno je 39-ero djece pa se u ovoj studiji analizira 291 dijete. Svaki je crvuljak postoperativno histološki pregledan u Zavodu za patologiju i citologiju KBC-a Zagreb i postavljena je konačna dijagnoza. U 160-ero djece preoperativno je načinjen ultrazvučni pregled trbuha te je zabilježena prisutnost ili odsutnost znakova upale crvuljka. Od ukupno 291 histološki pregledanog crvuljka njih 35 (12%) bilo je bez znakova upale, 44 (15,1%) bilo ih je u kataralnom stadiju upale, 153 (52,6%) flegmonozno, a 58 (19,9%) gangrenozno promijenjeno te je u jednog dječaka (0,3%) crvuljak bio perforiran. Srednja vrijednost (bodovnog iznosa prema Alvaradovu sustavu bodovanja) za djecu koja su imala histološki nalaz inocentnog (‘nevinog’) crvuljka i kataralne upale jest 6, za flegmonozne crvuljke 7, a gangrenozne 8. Dječak s perforiranim crvuljkom imao je zbroj bodova 6. Analizirane su osjetljivost, specifičnost i pozitivna prediktivna vrijednost kada je zbroj 7 i veći, a negativna vrijednost kada je zbroj 5 i manji. Osjetljivost Alvaradova bodovnog sustava u ispitivanoj skupini jest 68,9%, a specifičnost 52,9%. Pozitivna je prediktivna vrijednost 91,7%, a negativna 99%. Alvaradov zbroj statistički je značajno veći u djece s flegmonoznom upalom crvuljka negoli kod onih s negativnim nalazom (p = 0,003) i kataralnom upalom (p = 0,007). Kod djece koja su imala gangrenoznu upalu crvuljka u odnosu prema inocentnim i kataralno promijenjenima također je statistički značajna razlika Alvaradova zbroja (p < 0,001). U djece s flegmonozno i gangrenozno upalno promijenjenim crvuljkom nema statistički značajne razlike Alvaradova zbroja (p = 0,054), kao ni kod histoloških dijagnoza kataralne upale i inocentnog crvuljka (p = 0,998). Od ukupnog broja apendektomirane djece u njih 160-ero (54,9%) načinjen je preoperativni ultrazvučni pregled trbuha. Od svih ultrazvučnih nalaza njih 82 (51,2%) potvrđena su histološkom dijagnozom. Od ultrazvučnih nalaza koji nisu histološki potvrđeni bila su 64 (40%) lažno negativna i 14 (8,8%) lažno pozitivnih. Ultrazvučno pozitivan nalaz upalnih promjena crvuljka ima pozitivnu prediktivnu vrijednost 84,1%, a negativan nalaz 11,1%. Alvaradov sustav bodovanja u djece nije klinički pouzdan pokazatelj pozitivnih nalaza akutne upale crvuljka, ali ima visoku prediktivnu vrijednost negativnih apendektomija.
Summary
The Alvarado scoring (AS) system was created with the intention to reduce the number of negative appendectomies. It is used in both the adult and pediatric populations, but the number of negative appendectomies is rarely lower than 10%. In order to test the reliability of the system, an analysis was done on the correlation of the Alvarado score and the histological diagnoses of children who underwent appendectomy for suspected acute appendicitis. This retrospective study was conducted at the Department of Pediatric Surgery of the University Hospital Center Zagreb in the period between January 2014 and December 2016, and included 330 children with the clinical diagnosis of acute appendicitis. The children were included regardless of the method of appendectomy. As 39 of them were excluded due to incomplete medical records, only 291 children were analyzed. Each appendix was subjected to postoperative histological examination, after which the final diagnosis was made. Abdominal ultrasound was performed in 160 children to detect whether there were signs of appendicitis. 291 appendices were histologically examined, of which 35 (12%) were without inflammatory signs, 44 (15.1%) were in the catarrhal, 153 (52.6 %) in the phlegmonous, and 58 (19.9 %) in the gangrenous stage of inflammation; one boy (0.3 %) had a perforated appendix. The average value of the Alvarado score in children with histologically innocent or catarrhal appendix was 6, in those with phlegmonous 7, and in those with gangrenous 8. The boy with the perforated appendix had a score 6. Sensitivity, specificity, and positive predictive value (PPV) with the cut-point of 7, as well as negative predictive value (NVP) with the cut-point of 5, were analyzed. In the tested group, AS sensitivity and specificity were 68.9% and 52.9%, respectively. Positive predictive value was 91.7% and negative predictive value was 99%. AS was statistically significantly higher in children with phlegmonous appendicitis than in those with innocent appendix (p = 0.003) or with a catarrhal stage of inflammation (p = 0.007), as well as in children with gangrenous appendicitis compared to those with innocent and catarrhal appendicitis (p < 0.001). There was no statistically significant difference between AS in children with phlegmonous and gangrenous appendicitis (p = 0.054), and neither between AS in those with catarrhal and innocent appendix (p = 0.998). The abdominal ultrasound examination was performed preoperatively in 160 (54.9%) of all operated children. Only 82 (51.2%) of all ultrasound findings were consistent with the final histological diagnosis. Among those incongruous findings, there were 64 (40%) false negative and 14 (8.8%) false positive ones. Ultrasound showed the presence of appendicitis with a PPV of 84.1%, but for exclusion of the diagnosis NPV was 11.1 %. AS is not a reliable clinical indicator of the inflammatory signs of appendicitis in children, but still has a high predictive value for negative appendectomies.
