小儿急性阑尾炎临床诊疗特点及病原学分析

Clinical features and pathogenic analysis of acute appendicitis in children

目的分析总结小儿急性阑尾炎诊治要点及病原学特点。方法回顾性分析2018年1月1日至11月30日我院胃肠外科收治的149例小儿急性阑尾炎病例,总结临床特点、辅助检查、治疗效果、细菌培养及药敏结果。结果①本组患儿平均年龄7岁7个月,男女比例1.57∶1.00。②临床表现主要为腹痛(99.32%)、消化道症状(79.87%)、发热(65.77%),所有患儿查体有腹部压痛,可伴有反跳痛(81.21%)、肌紧张(77.18%)等腹膜炎体征,不同年龄组临床症状及体征发生率无明显差异。③不同病理类型组患儿外周血白细胞计数、中性粒细胞百分比、C反应蛋白(CRP)值比较差异有统计学意义(P<0.05),坏疽性阑尾炎组血象较高,而单纯性阑尾炎组较低,但不同年龄组外周血白细胞计数、中性粒细胞百分比、CRP值差异无统计学意义;本组超声检查阳性率82.55%,B超发现以腹腔炎性病变为主。④本组急性单纯性阑尾炎14例(9.40%),急性化脓性阑尾炎49例(32.89%),急性坏疽性阑尾炎86例(57.71%),不同病程中各病理类型阑尾炎发生率差异有统计学意义(P<0.001),病程>1 d,则坏疽性阑尾炎比例明显升高;腹腔残余感染为术后最常见并发症(29.53%),坏疽性阑尾炎术后更容易出现腹腔残余感染,各种病理类型之间腹腔残余感染发生率差异有统计学意义(χ^2=24.463,P<0.001)。⑤本组脓液细菌培养率75.84%,培养阳性率为81.42%,以G-菌为主(81.15%),G-菌仍以大肠埃希菌(70.70%)和铜绿假单胞菌(22.22%)为主;药敏结果提示美罗培南、亚胺培南对G+及G-菌均有高敏感度,半合成青霉素类、三代头孢对G-菌敏感度较高。⑥本组患儿术后使用二联或三联抗感染方案取得良好疗效,有效率分别为97.22%与99.10%,当二联、三联抗感染疗效欠佳时,升级抗生素为美罗培南或泰能等特殊级抗生素后均治愈。结论小儿急性阑尾炎临床表现缺乏典型性,以右下腹痛及固定压痛为主要诊断依据,外周血检查及腹部B超等辅助检查仅作为参考,一旦临床诊断急性阑尾炎,应尽早手术,术后规范使用抗生素。

Objective To analyze the clinical features and pathogen characteristics of acute appendicitis in children.Methods We retrospectively reviewed the data of 149 children with acute appendicitis treated in our hospital between January 1,2018 and November 30,2018,and analyzed their clinical features,laboratory test results,therapeutic effects,results of bacterial culture and drug sensitivity of the bacteria.Results①The children had an average age of 7 years and 7 months with a male to female ratio of 1.57∶1.00.②The main clinical manifestations included abdominal pain(99.32%),digestive tract symptoms(79.87%)and fever(65.77%).All the children had abdominal tenderness,could be accompanied by such peritonitis signs as rebound pain(81.21%)and muscle tension(77.18%).③The incidence of clinical symptoms and signs did not differ significantly among different age groups.The children with different pathological types showed significant differences in peripheral blood white blood cell(WBC)counts,percentage of neutrophils and C-reactive protein(CRP)level(P<0.05),and WBC counts were higher in children with gangrenous appendicitis and lower in children with uncomplicated appendicitis;these parameters did not differ significantly among different age groups.The positive rate of ultrasonography was 82.55%in these children,and abdominal inflammatory lesion was the predominant finding by B-mode ultrasound.④Of the 149 children,14 had acute simple appendicitis(9.40%),49 had acute suppurative appendicitis(32.89%)and 86 had acute gangrenous appendicitis(57.71%).The incidences of appendicitis of different pathological types differed significantly among children with different disease courses(P<0.001);a disease course over 1 d was associated with a significantly increased risk of gangrenous appendicitis.Residual abdominal infection was the most common postoperative complication(29.53%),which was more likely in cases of gangrenous appendicitis,and its incidence differed significantly among different pathological types(chi-square=24.463,P<0.001).⑤Bacterial culture of the pus was performed in 75.84%of the cases,and the positive rate was 81.42%.Most of the pathogens identified were Gramnegative bacteria(81.15%),consisting predominantly of Escherichia coli(70.70%)and Pseudomonas aeruginosa(22.22%).Drug sensitivity tests showed that the pathogenic bacteria(both Gram-negative and-positive)were highly sensitive to meropenem and imipenem;the gram-negative bacteria showed a high sensitivity to semisynthetic penicillins and the third generation cephalosporins.⑥The children received double or triple antibiotic therapies after the operation,which resulted in positive response rates of 97.22%and 99.10%,respectively.The children showing poor responses to the double and triple therapies were cured after treatment with the special class antibiotics such as meropenem and imipenem.Conclusion The clinical manifestations are atypical in children with acute appendicitis,for which a clinical diagnosis is made based primarily on the presence of right lower abdominal pain and fixed tenderness,and peripheral blood tests and abdominal B-ultrasound only have limited diagnostic values.Once diagnosed,prompt operation should be performed with standardized use of postoperative antibiotics in children with acute appendicitis.