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Diagnostic accuracy and prognostic utility of D Dimer in acute appendicitis in children

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Abstract

The objective was to determine the uselfulness of D Dimer (DD) as a diagnostic or prognostic marker in acute appendicitis (AA) in children using a prospective observational study in the pediatric emergency department of a tertiary hospital. We enrolled 135 patients aged 1–16 years presenting with abdominal pain consistent with AA, who required laboratory studies. We analyzed clinical, analytical variables and histopathology findings (when they underwent surgery). Statistical analysis was conducted using SPSS. 38.5 % of the children were clinically diagnosed with AA (n = 52), confirmed by pathology in 51 patients. 55.8 % were gangrenous appendicitis. Leucocyte count, C-reactive protein (CRP), and DD were higher in the AA group and in the gangrenous appendicitis group (p < 0.05), with highest values of DD in the gangrenous group. The area under the receiving operating characteristics (ROC) curve for DD in the diagnosis of AA is 0.66 (95 % CI 0.56–0.75). For DD cut-off point of 230 ng/mL, sensitivity (Se) was 0.40, specificity (Sp) 0.80, positive predictive value (PPV) 0.57, and negative predictive value (NPV) 0.66. The area under the ROC curve for DD in children with gangrenous appendicitis is 0.93 (95 % CI 0.87–1). A DD cut-off point of 230 ng/mL exhibited: Se = 0.69, Sp = 1, PPV = 1 and NPV = 0.72.

Conclusion: DD levels increase in patients with AA. Although it does not constitute a useful diagnostic marker, it could be a good prognostic marker.

What is known:

● In pediatric emergency settings, the diagnosis of AA is frequent and can be challenging.

● Laboratory data have taken up an important role, the most useful markers being C-reactive protein (CRP) and leukocyte count, and more controversially, procalcitonin (PCT).

What is new:

● DD has recently been linked in adults to acute surgical abdomen.

● The obstruction of the appendix and inflammatory response thought to be important in the physiopathology of AA could increase DD, making it an interesting diagnostic or prognostic marker.

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Abbreviations

AA:

Acute appendicitis

CRP:

C-reactive protein

CT:

Computerized tomography

DD:

D Dimer

ED:

Emergency department

IQR:

Interquartile range

NPV:

Negative predictive value

PCT:

Procalcitonin

PPV:

Positive predictive value

ROC:

Receiving operating characteristics

Se:

Sensibility

Sp:

Specificity

UAP:

Unspecified abdominal pain

US:

Ultrasound

UTI:

Urinary tract infection

WBC:

White blood count

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Acknowledgements

Jose Maria Bellón Cano, Department of Statistics: support for the design of projects and statistical analysis. The authors would like to thank the Sanitary Investigation Institute, Hospital General Universitario Gregorio Marañón, Madrid, for participating in statistical analysis.

Conflicts of interest

There are no potential conflicts of interests.

Author contribution

Maria Concepcion Míguez Navarro (MCMN) conceived the study. Julie Cayrol (JC) and MCMN designed the study and obtained ethics comittee approval. JC, MCMN, and Rafael Marañón Pardillo (RMP) supervised the conduct of the study. JC and MCMN supervised data collection, managed the data, and conducted statistical analysis. Gloria Guerrero Marquez managed and supervised drawing of blood and conducted telephone follow-ups. Cristina Tomatis Souberville participated in data collection and statistical analysis. Isabel Simal Badiola conducted and managed participation of the surgery department and the correct follow-up of appendix samples and its analysis by the pathology department. MCMN and RMP provided statistical advice on study design. The manuscript was written by JC, corrected by MCMN and RMP, and revised and approved by all authors. JC takes responsibility for the paper as a whole.

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Authors and Affiliations

  1. Department of Pediatrics, Hospital General Universitario Gregorio Marañón, Madrid, Spain

    Julie Cayrol & Cristina Tomatis

  2. Department of Pediatrics, Division of Emergency Medicine, Hospital General Universitario Gregorio Marañón, Madrid, Spain

    Maria Concepción Miguez & Rafael Marañón

  3. Department of Nursing, Pediatrics, Emergency Medicine, Hospital General Universitario Gregorio Marañón, Madrid, Spain

    Gloria Guerrero

  4. Department of Pediatric Surgery, Hospital General Universitario Gregorio Marañón, Madrid, Spain

    Isabel Simal

  5. Hospital Materno-Infantil Gregorio Marañón, Calle O’Donnell 48-50, 28009, Madrid, Spain

    Julie Cayrol

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  1. Julie Cayrol
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  2. Maria Concepción Miguez
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Correspondence to Julie Cayrol.

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Communicated by Jaan Toelen

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Cayrol, J., Miguez, M.C., Guerrero, G. et al. Diagnostic accuracy and prognostic utility of D Dimer in acute appendicitis in children. Eur J Pediatr 175, 313–320 (2016). https://doi.org/10.1007/s00431-015-2632-3

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  • DOI: https://doi.org/10.1007/s00431-015-2632-3

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