Desenlaces clínicos asociados con la localización del apéndice en niños con apendicitis aguda
Autor: Escobar Echeverry, Jhon Marino
Asesor: Valero Halaby, Juan Javier
Fecha: 2021-01-05
Programa: Bogotá - Medicina - Especialidad en Cirugía Pediátrica
Facultad: Facultad de Medicina

Resumen: IMPORTANCE Appendix location in children varies from what can be found in literature and leads to different clinical outcomes.
OBJECTIVE To describe the association between appendix location and perforation in children with acute appendicitis (AA) and compare differences in clinical and imaging findings.
DESIGN, SETTING, AND PARTICIPANTS Prospective observational cohort study of 412 children aged 2 through 18 years who underwent laparoscopic appendectomy in a quaternary children’s hospital (HOMI) between November 2019 and March 2020; the diagnosis of AA due to pathology was confirmed and clinical history data were taken. Of the 550 eligible patients approached, 412 enrolled in the study.
INTERVENTIONS Acute appendicitis diagnostic was confirmed with pathology, clinical history data were taken and appendix location was classified as retrocecal (RA), pelvic (PEA), right lower quadrant (RLQ) and an intraoperative photograph was taken for confirmation. 
MAIN OUTCOMES AND MEASURES 
The primary measures assessed were appendix location (RA 25%, PEA 33%, RLQ 42%), differences in time of symptoms (RA &gt;48 hours in 54.5% of patients, p: 0.001), ecographic diagnostic (RA 25.9%, PEA 24.6%, RLQ 49.3%, p: 0.01). The primary outcome assessed was appendix perforation 37,8% (46% PEA, p: 0.001)
RESULTS. Among 412 patients who were enrolled (median age, 10.5 years; 43.9% girls). The location of the appendix was documented in RLQ 36,3%, PEA 34,5%, RA 27,2%. The average progression of symptoms was 1,8 days (range 0-15), finding that in RA 45,6% were 2 days or more. There was no difference in symptoms associated with the location of the appendix except for the presence of diarrhea, which was more frequent in the pelvic location (32,4%).
Hypersensitivity to palpation was more frequent in RLQ (62,7%) and lower in PEA (52,1%). Percussion tenderness was present 83% in RA and only  69% in PEA. The blood count parameters had a similar behavior in all groups. Ultrasound was performed in 205 patients, 79,7% visualized in RLQ  in comparison to 54,5% in PSA.
Within the operative findings perforation was found 45,1% in PEA (p=0,02) and only 30.4% in the RLQ. In cases of perforated appendicitis, 26.7% of RA had generalized peritonitis compared to 46.7% of PEA.
CONCLUSION AND RELEVANCE.The appendix location in children with AA is different from that reported in the literature for the global population in cadaver studies. Pelvic localization was associated statistically significantly with the presence of perforation, possibly because signs of peritoneal irritation are less common in these children. Furthermore when ultrasound is performed, the appendix is less commonly visualized.