急診兒童急性闌尾炎之診斷指引

Guidelines for acute pediatric appendicitis diagnosis at emergency department

背景：急性腹痛是小兒急診很常見的急症，而造成腹痛的原因有很多包括外科急症，急性闌尾炎是其中最重要原因，也常造成確診上的挑戰，在急診室的醫師需要做出診斷才能及時作適當處置，本文獻回顧急診的兒童腹痛提出診斷策略。方法：回顧2010年至2014年以急診的兒童腹痛為主題之文獻，針對在急診室診斷為急性闌尾炎病人的各項症狀數據指標及預測值作分析討論。結果：從病史、症狀、徵候作急性闌尾炎診斷依據常造成延誤診斷，白血球增加對急性闌尾炎預測值偏低，CRP值上升偵測闌尾炎穿孔及膿瘍敏感度有83%至90%，腹部電腦斷層掃描及超音波影像檢查作急性闌尾炎診斷工具，各有92%至97%、86%至90%敏感度及94%至97%、92%至95%專一性，闌尾炎評分系統（PAS）以多項相關指標綜合評估，設計出有預測度的評估，可作為急診在兒童腹痛診斷上有用的工具。結論：各單項指標在急性闌尾炎診斷上都有限制，闌尾炎評分系統作為急診在兒童腹痛診斷上的評估工具，比較有標準的實用價值，應配合國內醫療環境及就醫文化訂立適合的評分系統。

Background: Acute abdominal pain is a common condition encountered in the pediatric emergency department. The patients with abdominal pain might be caused by various etiologies including pathology requiring surgical intervention. Acute appendicitis is the most important cause and diagnosis is a daunting clinical challenge. The physician at the emergent department (ED) needed to make an initial diagnosis and appropriated management. To review the topic of abdominal pain of children in emergency department, there is a diagnostic problem because it is difficult to confirm that a surgical indication for pediatric abdominal pain. This review comments on the strategies of decision making for pediatric abdominal pain at ED. Method: A literature search using MEDLINE published between 2010 and 2014, and we reviewed all relevant articles. The articles were reviewed to determine the predictive values of different parameter for diagnosis of suspected appendicitis in ED. Result: The classical history, symptoms and signs led to the consideration of appendicitis. However, it makes a high-risk disease for delay or missed diagnosis. WBC count and CRP are used to assist in making the diagnosis. An elevated WBC has a low predictive value and CRP was suggested more sensitive (83~90%) in detecting perforation and abscess formation. Imaging with CT or ultrasonography is valuable tool in evaluation of suspected appendicitis. The estimate sensitivity and specificity in CT is 92~97% and 94~97%, in ultrasonography is 86~90% and 92~95%. Several Appendicitis scoring systems (PAS) were designed with parameters related to abdominal pain to predict and recommend the need for surgery. Conclusions: All the parameters had limitation to make an accurate diagnosis for acute appendicitis in children. Pediatric appendicitis scoring systems provided a more rationale strategy for evaluation of abdominal pain in children in ED.