Does this child have appendicitis?
Does this child have appendicitis?
复制标题
DOI：
10.1001/jama.298.4.438
复制
发表时间：
2007-07-25
影响因子：
120.7
通讯作者：
Rice, Henry E.
中科院分区：
文献类型：
--
作者：
Bundy, David G.;Byerley, Julie S.;Rice, Henry E.
儿童腹痛的背景评估可能很困难。对儿童阑尾炎的快速、准确诊断降低了这一引起儿童腹痛的常见原因的发病率。临床评估有助于确定(1)哪些腹痛和可能被诊断为阑尾炎的儿童应该立即接受手术会诊以进行潜在的阑尾切除术，以及(2)哪些表现可疑的阑尾炎的儿童应该接受进一步的诊断评估。目的系统地评估症状、体征和基本实验室检查结果的精确度和准确性，以评估可能患有阑尾炎的儿童。资料来源：我们检索了MEDLINE(1966-03)和Cochrane数据库中的英文文章，以及体检教科书和检索文章的书目。如果(1)提供了18岁或18岁以下被诊断为阑尾炎的儿童的基本数据，则纳入研究选择研究；(2)提供病史、体检结果或实验室基础资料；(3)经手术病理、临床观察或随访证实或排除阑尾炎。在检查的256篇全文文章中，42篇符合纳入标准。数据提炼42篇研究中的25篇被赋予3级或更高的质量等级。结果在有腹痛的儿童中，发热是与阑尾炎有关的唯一最有用的体征；发烧增加了阑尾炎的可能性(似然比[LR]，3.4；95%可信区间[CI]，2.4-4.8)，反之，发烧降低了阑尾炎的风险(似然比[LR]，0.32；95%可信区间，0.16-0.64)。在被怀疑为阑尾炎并接受评估的特定儿童群体中，反跳压痛会使患阑尾炎的几率增加两倍(汇总LR，3.0；95%可信区间，2.3-3.9)，而如果没有反弹，则会降低患阑尾炎的可能性(汇总LR，0.28；95%可信区间，0.14-0.55)。中腹疼痛转移到右下腹痛(LR范围为1.9-3.1)比右下腹痛本身更增加阑尾炎的风险(汇总LR，1.2；95%CI，1.0-1.5)。白血球计数低于10000个/亩的L降低了患阑尾炎的可能性(汇总LR，0.22；95%CI，0.17-0.30)，中性粒细胞绝对值在6750个/亩L或更低(LR，0.06；95%CI，0.03-0.16)也是如此。症状和体征结合起来最有用，特别是对于不需要进一步评估或干预的儿童。结论尽管临床检查不能确定阑尾炎的诊断，但它有助于确定哪些腹痛儿童需要立即手术评估以考虑阑尾切除术，哪些儿童可能需要进一步诊断评估。需要更多针对儿童的、按年龄分层的数据，以提高诊断儿童阑尾炎的临床检查的效用。
Context Evaluation of abdominal pain in children can be difficult. Rapid, accurate diagnosis of appendicitis in children reduces the morbidity of this common cause of pediatric abdominal pain. Clinical evaluation may help identify ( 1) which children with abdominal pain and a likely diagnosis of appendicitis should undergo immediate surgical consultation for potential appendectomy and ( 2) which children with equivocal presentations of appendicitis should undergo further diagnostic evaluation.Objective To systematically assess the precision and accuracy of symptoms, signs, and basic laboratory test results for evaluating children with possible appendicitis.Data Sources We searched English-language articles in MEDLINE ( January 1966 March 2007) and the Cochrane Database, as well as physical examination textbooks and bibliographies of retrieved articles, yielding 2521 potentially relevant articles.Study Selection Studies were included if they ( 1) provided primary data on children aged 18 years or younger in whom the diagnosis of appendicitis was considered; ( 2) presented medical history data, physical examination findings, or basic laboratory data; and ( 3) confirmed or excluded appendicitis by surgical pathologic findings, clinical observation, or follow-up. Of 256 full-text articles examined, 42 met inclusion criteria.Data Extraction Twenty-five of 42 studies were assigned a quality level of 3 or better. Data from these studies were independently extracted by 2 reviewers.Results In children with abdominal pain, fever was the single most useful sign associated with appendicitis; a fever increases the likelihood of appendicitis ( likelihood ratio [LR], 3.4; 95% confidence interval [CI], 2.4-4.8) and conversely, its absence decreases the chance of appendicitis ( LR, 0.32; 95% CI, 0.16-0.64). In select groups of children, in whom the diagnosis of appendicitis is suspected and evaluation undertaken, rebound tenderness triples the odds of appendicitis ( summary LR, 3.0; 95% CI, 2.3-3.9), while its absence reduces the likelihood ( summary LR, 0.28; 95% CI, 0.14-0.55). Midabdominal pain migrating to the right lower quadrant ( LR range, 1.9-3.1) increases the risk of appendicitis more than right lower quadrant pain itself ( summary LR, 1.2; 95% CI, 1.0-1.5). A white blood cell count of less than 10 000/ mu L decreases the likelihood of appendicitis ( summary LR, 0.22; 95% CI, 0.17-0.30), as does an absolute neutrophil count of 6750/ mu L or lower ( LR, 0.06; 95% CI, 0.03-0.16). Symptoms and signs are most useful in combination, particularly for identifying children who do not require further evaluation or intervention.Conclusions Although the clinical examination does not establish a diagnosis of appendicitis with certainty, it is useful in determining which children with abdominal pain warrant immediate surgical evaluation for consideration of appendectomy and which children may warrant further diagnostic evaluation. More child-specific, age-stratified data are needed to improve the utility of the clinical examination for diagnosing appendicitis in children.