Clinical, Laboratory and Imaging Predictors of Complicated Appendicitis in Children: A Multivariate Analysis

Clinical, Laboratory and Imaging Predictors of Complicated Appendicitis in Children: A Multivariate Analysis | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Clinical, Laboratory and Imaging Predictors of Complicated Appendicitis in Children: A Multivariate Analysis Stéphane Emile Montcharmont Sada, Francisco M Bravo Rojas, María Riba Olea, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7187653/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Objective To identify clinical, laboratory, and imaging factors associated with complicated appendicitis in a Mexican pediatric population using multivariate analysis. Methods This retrospective, observational, analytical, cross-sectional study was conducted at a tertiary care hospital in Mexico City. A total of 134 patients under 18 years of age with a histopathological diagnosis of acute appendicitis were included from January 2019 and March 2024. Cases presenting with gangrene, perforation, or abscess were classified as complicated appendicitis. Clinical, laboratory, and imaging variables were analyzed using bivariate and multivariate logistic regression. Results Complicated appendicitis was present in 28.3% of patients. In multivariate analysis, fever at admission (OR 5.58, 95% CI: 1.89–16.42, p = 0.002), band cell percentage (OR 1.22, 95% CI: 1.09–1.36, p = 0.001), hyponatremia (OR 0.75, 95% CI: 0.60–0.92, p = 0.004), and presence of an appendicolith (OR 1.42, 95% CI: 1.10–1.83, p = 0.006) were significantly associated with complicated cases. Conclusion Simple and readily available variables at hospital admission—such as fever, serum sodium levels, bandemia, and the presence of an appendicolith—can aid in stratifying the risk of complicated appendicitis in children, facilitating more timely and targeted diagnostic and therapeutic decisions. Acute appendicitis complicated appendicitis pediatrics risk factors multivariate analysis Figures Figure 1 Introduction Acute appendicitis is the most common abdominal surgical emergency in the pediatric population and continues to be a significant cause of morbidity, particularly when it progresses to complicated forms (1,2). The pathophysiology often begins with obstruction of the appendiceal lumen, typically due to appendicoliths or lymphoid hyperplasia, resulting in secretory accumulation, increased intraluminal pressure, vascular compromise, and ischemia, eventually leading to bacterial invasion, necrosis, and perforation (3,4). In advanced stages, the inflammatory process may result in localized or generalized peritonitis, often accompanied by systemic manifestations such as hyponatremia, which is thought to the arise from inflammatory mediator release and increased capillary permeability (5). Despite advancements in diagnostics and treatment, the rate of complicated appendicitis (CA) remains high, especially in children under five years of age, with reported rates up to 80% (6,7). Complicated cases are associated with longer hospitalizations, increased antibiotic use, and greater postoperative complications (8,9). Early diagnosis remains challenging due to nonspecific symptoms, limited communication in pediatric patients, and variable clinical progression (8,10). Several tools have been proposed to support clinical judgment, including the Pediatric Appendicitis Score (PAS), which incorporates clinical and laboratory data with variable sensitivity and specificity (11,12). A high PAS may indicate increased risk, particularly when associated with imaging findings such as increased appendiceal diameter or elevated C-reactive protein levels (CRP) (7,13). Clinical features such as symptom duration over 24 hours, persistent fever, the presence of an appendicolith on imaging, leukocytosis, neutrophilia, and bandemina have been linked to increased risk of complication rates (6,14,15). Among these, hyponatremia has gained attention as a marker of systemic inflammation, with consistent associations reported in multiple studies and meta-analyses (14,15). These findings have prompted the development of prediction models that integrate clinical, laboratory, and imaging variables to enhance early detection of complicated cases. However, significant heterogeneity persists across studies, limiting generalizability. This study aims to identify clinical, laboratory, and imaging factors associated with complicated appendicitis in a Mexican pediatric cohort. Materials and Methods This cross-sectional study was conducted in a cohort of pediatric patients under 18 years of age with a histopathological diagnosis of acute appendicitis, treated at a private tertiary care hospital in Mexico City between January 2019 and March 2024. Patients were included if they had complete medical records, a confirmed histopathological diagnosis of appendicitis, and detailed records including clinical, laboratory, and imaging data at the time of admission. Cases with alternative surgical diagnoses or incomplete records were excluded. The final sample included 134 patients. The dependent variable was the presence of complicated appendicitis, defined as gangrenous, perforated, or associated with abscess formation as documented during surgery. Non-complicated cases included edematous or suppurative appendicitis without evidence of necrosis or perforation. Statistical analysis was performed using IBM SPSS Statistics version 28.0. Descriptive analysis were reported as absolute frequencies and percentages for categorical variables, and as means ± standard deviations or means with interquartile ranges (IQR) for continuous variables, according to their distribution assessed by the Kolmogorov–Smirnov test. Group comparisons were conducted using chi-square or Fisher’s exact test for categorical variables, and Student’s t-test or Mann–Whitney U for quantitative variables, as appropriate. Bivariate logistic regression was used to estimate the association between independent variables and the presence of complicated appendicitis, reporting odds ratios (OR) with 95% confidence intervals (95% CI). Variables with a p-value < 0.20 in the bivariate analysis were included into a multivariate binary logistic regression model using the Enter method. Statistical significance was set at p < 0.05. Model fit was assessed using the Hosmer–Lemeshow test, and the Nagelkerke R-squared coefficient was reported. The study protocol was reviewed and approved by the Institutional Ethics Committee. Given its retrospective nature, informed consent was not required. No missing data were identified for the variables included in the multivariate analysis. Results A total of 134 patients with a histopathological diagnosis of acute appendicitis were included. Among them, 38 cases (28.3%) were classified as complicated appendicitis, defined as gangrenous, perforated, or with abscess formation, while the remaining 96 cases (71.6%) were classified as non-complicated apendicitis, including edematous or suppurative appendicitis forks without evidence of perforation or necrosis. All cases had complete clinical records, including documentation of clinical, laboratory, and imaging data at the time of admission. When comparing categorical clinical characteristics between the two groups (table 1), fever was significantly more common in the complicated group (94.7%) than non-complicated group (28.1%; p < 0.001). McBurney's sign was more commonly observed in the complicated group (84.2%) compared to the non-complicated group (81.25%; p = 0.023). Nausea and/or vomiting were more frequent in non-complicated cases (64.6%) than in complicated ones (21.6%; p < 0.001). Diarrhea was reported in 19.7% of the non-complicated cases and 34.2% of the complicated cases, though this difference did not reach statistical significance (p = 0.058). Appendicoliths were more frequently identified in patients with complicated appendicitis (26.3%) than in those with non-complicated forms (8.3%; p = 0.006), and phlegmon was observed exclusively in the complicated group (23.7%; p = 0.041). Symptom duration prior to medical consultation also differed significantly: in the complicated group, 21.1% presented within 12 hours, 31.6% between 12 and 24 hours, and 47.4% after 24 hours. In contrast, among non-complicated cases, 52.1% presented within 12 hours, 18.7% between 12-24 hours, and 29.1% after 24 hours (p = 0.005). There were no significant differences between groups regarding the surgical approach (p = 0.245). Intraoperative classification of appendicitis types revealed that 52 out of 96 non-complicated cases (54.1%) were edematous and 45.8% suppurative. Among complicated cases, 7 (18.4%) were gangrenous and 31 (81.5%) perforated (Figure 1). Analysis of quantitative variables (Table 2) showed significant higher band counts in the complicated group (median 10%, IQR 3–15.8) compared to non-complicated cases (median 3%, IQR 0–7; p < 0.001). Serum sodium levels were lower in the complicated group (mean 133.2 ± 2.8 mEq/L) compared to the non-complicated group (mean 138.1 ± 3.6 mEq/L, p = 0.039). Appendiceal diameter measured on ultrasound was greater in the complicated group (median 12 mm, IQR 8–16) versus the non-complicated group (median 8 mm, IQR 4.5–11.5), though the difference was not significant (p = 0.173). Total leukocyte count was higher in complicated cases (mean 15.6 ± 5.4 x10³/μL) than in the non-complicated group (mean 14.0 ± 4.4 x10³/μL; p = 0.077). Mean patient age was slightly lower in the complicated group (9.37 ± 4.54 years) when compared to non-complicated patients (10.75 ± 3.81 years; p = 0.076). No significant difference was found in neutrophil percentage between groups (p = 0.380). In the bivariate analysis (Table 3), fever at admission was associated with a more than threefold increase in the likelihood of complicated appendicitis (OR 3.30, 95% CI: 1.35-8.34; p = 0.032). Appendicolith presence was also significantly associated with complications (OR 1.42, 95% CI: 1.10-1.83; p = 0.006). Each 1% in band cell percentage increased the odds of complication by 22% (OR 1.22, 95% CI: 1.09-1.36; p < 0.001). Conversely, each 1 mEq/L increase in serum sodium was associated with a 25% reduction in complication risk (OR 0.75, 95% CI: 0.60-0.92; p = 0.039). Other variables showed a borderline associations.. Higher leukocyte count at admission was associated with a 5% increase in the risk of complicated appendicitis for every additional 1,000 cells/μL (OR 1.05, 95% CI: 0.99–1.12, p = 0.077), younger age at diagnosis also appeared related to higher risk, with an 8% decrease in the likelihood of complicated appendicitis per additional year of age (OR 0.92, 95% CI: 0.81–1.04, p = 0.076). A progressive association was also identified between symptom duration and the likelihood of complication. Compared to patients who consulted within 12 hours of pain onset, those who sought care between 12 and 24 hours had twice the likelihood of presenting with complicated appendicitis (OR 2.00, 95% CI: 0.85–4.70, p = 0.169), while those who presented after 24 hours showed a 119% increase in that likelihood (OR 2.19, 95% CI: 1.01–4.74, p = 0.072). The multivariate logistic regression model was (Table 4) constructed including variables with a p < 0.20 in the bivariate analysis. The final model included: age, leukocyte count, band count percentage, serum sodium level, appendiceal diameter, presence of fever, and presence of appendicolith. In this model, band count percentage (OR 1.22, 95% CI: 1.09–1.36, p = 0.001), sodium level (OR 0.75, 95% CI: 0.60–0.92, p = 0.004), presence of fever (OR 5.58, 95% CI: 1.89–16.42, p = 0.002), and presence of appendicolith (OR 1.42, 95% CI: 1.10–1.83, p = 0.006) remained significantly associated factors. The model showed good fit according to the Hosmer–Lemeshow test (χ² = 4.11, p = 0.767), indicating that no significant differences between observed and expected frequencies. This suggests the model achieves a coherent representation of the data without overfitting, and the observed distribution of complicated appendicitis is consistent with the predicted distribution based on the included variables. Moreover, the Nagelkerke R-squared coefficient was R² = 0.043, indicating that the model explained approximately 4.3% of the total variability observed in the occurrence of complicated appendicitis. While this reflects modest explanatory power, it is important to note that in clinical studies involving multiple factors, low R² values are common and do not necessarily invalidate the model's utility—particularly when the retained variables are statistically significant and clinically plausible. Discussion Complicated acute appendicitis, encompassing perforation, gangrene, or abscess, represents approximately 15–30% of pediatric cases and is associated with higher morbidity, risk of abscess formation, longer hospital stays, and increased healthcare costs (16,17). Early recognition of predictive factors is therefore critical to optimize management, including timely antibiotics, surgery, or drainage. In the last decade, various predictors have been proposed; our study focused on clinical and paraclinical variables with physiological plausibility. In our cohort, four factors were significantly associated with complicated appendicitis: fever at admission, hyponatremia, elevated band count percentage, and the presence of an appendicolith. Fever is a well-established marker of systemic inflammation and a potential predictor of complicated appendicitis. Our findings partially support this concept, as complicated cases present more frequently with fever. Studies such as Zvizdić et al. (2021) have identified fever as an independent predictor of perforation (OR ~3.4) (18). From a mechanistic perspective, high fever reflects a raise in the hypothalamic set point (19) by cytokine-mediated immune activation (IL-1, IL-6, TNF-α), in the setting of transmural infection and peritonitis. However, some studies, Roushan et al. (2021), reported no significant difference in fever incidence between children with simple and complicated appendicitis (16.6% vs. 19.7%, p = 1.0) (14). Therefore, absence of fever does not rule out complication, especially in young children or those previously treated with antipyretics. Thus, fever should be interpreted with caution and in conjunction with other findings. Systemic inflammatory response is typically reflected in neutrophilic leukocytosis. In our cohort, patients with complicated appendicitis had higher average white blood cell counts and band percentages. This finding aligns with studies by Zvizdić et al. (18) and Howell et al. (17), which reported associations between leukocytosis, left shift, and perforation. However, Roushan et al. (14) found no significant difference in leukocyte counts between simple and complicated forms, highlighting the limited specificity of this marker when interpreted in isolation. Confounding factors such as dehydration, prior treatment, or timing of blood sampling may affect these values. Nevertheless, marked bandemia remains a relevant warning sign, as described in prior series (>20% bands) (17). One of the most consistent findings was hyponatremia, which was significantly associated with complicated appendicitis. This association is consistent with multiple retrospective, prospective, and meta-analytic studies (15,20,21). For example, Zhan et al. (2022) and Anand et al. (2022) described an approximate 3 mEq/L difference in sodium levels between complicated and non-complicated cases. Pogorelić et al. (2020) and Salam et al. (2023) reported mean sodium values of 132–133 mEq/L in complicated cases versus 138–139 mEq/L in non-complicated ones (22,23). Hyponatremia has been linked to non-osmotic secretion of antidiuretic hormone (ADH) induced by cytokines such as IL-6, resulting in free water retention and serum sodium dilution (24). Additionally, insensible fluid losses due to fever or tachypnea may contribute to this finding (25). Altogether, these data support the clinical value of low sodium as an early marker of disease severity. A sodium level <135 mEq/L in a child with suspected appendicitis should raise concern for perforation or abscess. The presence of an appendicolith was another significant factor associated with complications. Its pathophysiological in the role of luminal obstruction and mural necrosis is well established (3,4). Yoon et al. (2018) and Khan et al. (2019) demonstrated a higher risk of perforation in the presence of a fecalith (26,27). Furthermore, the presence of an appendicolith has been linked to a higher failure rate of nonoperative management (28,29), prompting suggestions to use it as an exclusion criterion for conservative treatment. In our study, the odds ratio for appendicolith decreased after adjustment for other variables, suggesting collinearity with fever or bandemia. Nevertheless, its statistical significance remained, reaffirming its predictive value. Taken together, these factors outline that a clinical, biochemical, and imaging profile can assist clinicians from the time of admission. Our findings enable early identification of children at higher risk for complications, facilitating more timely surgical decisions. We recommend incorporating these variables into scoring systems or management algorithms. Fever, bandemia, hyponatremia, and appendicolith should be considered for early risk stratification and to optimize intervention timing, reducing the likelihood of progression to generalized peritonitis and its sequelae (6,17,30). Conclusions In this pediatric cohort, fever at admission, hyponatremia, elevated band cell percentage, and the presence of an appendicolith were significantly associated with complicated forms of appendicitis. This findings highlight the clinical value of simple and readily accessible variables available at the time of hospital admission for early risk stratification. Timely recognition of these factors may enhance both diagnostic accuracy and therapeutic decision-making in pediatric settings. Our results support the development of integrated predictive tools that combine clinical, laboratory, and imaging data at presentation. Such tools may facilitate earlier identification of high-risk cases in emergency departments and contribute to more effective initial management protocols. Declarations Funding. No funding was received for the conduct of this study. Conflict of interest. The authors declare that they have no conflicts of interest that could have influenced the results or interpretation of the study. Ethics approval and consent to participate. The study was approved by the relevant ethics committee. Consent for publication. Not applicable. Data availability. Not applicable. Materials availability. Not applicable. Code availability. No custom code was used in this study. Author contributions. All authors made substantial contributions to the conception and design of the study, data analysis, and manuscript writing. All authors reviewed and approved the final version of the manuscript. References AlFraih YS, AlMutawa R. 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DOI 10.1016/j.jpedsurg.2016.02.056 Kum HJ, Gang S, Kim DY. The Feasibility of Nonoperative Management (NOM) in Pediatric Acute Appendicitis in the Era of Coronavirus Disease-2019 (COVID-19). Adv Pediatr Surg. 2023;29(2):65. DOI 10.13029/aps.2023.29.2.65Annexes Tables Table 1. Comparison of categorical clinical variables between patients with complicated and uncomplicated appendicitis. Feature Complicated* Not complicated p+ n (38) % n (96) % Sex Male 24 63.1 63 65.6 0.787 Female 14 36.8 33 34.3 Type of surgery 0.245 Open appendectomy 14 36.8 46 47.91 Laparoscopic appendectomy 24 63.1 50 52 Symptoms Fever 36 94.7 27 28.1 0.041 McBurney's sign 32 84.2 78 81.25 0.023 Nausea/Vomiting 29 21.6 62 64.58 0.190 Diarrhea 13 34.2 19 19.7 0.058 Ultrasonographic findings Presence of appendicolith 10 26.3 8 8.3 0.006 Presence of plastron 9 23.6 0 0 0.041ᵩ Hours until care 24 hours 18 47.3 28 29.1 * Complicated appendicitis defined as the presence of surgical findings of perforation or gangrenous appendicitis during the procedure, + chi-square (χ²) # reference category, ᵩ Fisher's exact test Table 2 Comparison of quantitative variables between patients with complicated and uncomplicated appendicitis Complicated Not complicated p Age (years) 9.37 (±4.54) 10.75 (±3.81) 0.076 t BMI* (kg/m²) 17.89 (± 3.75) 18.76 (± 3.74) 0.227 t Hours elapsed since onset of abdominal pain 23 (15.25-43) 11.5 (7-24) 0.001 Ʋ Days of hospital stay 5 (1-9) 3 (1-5) < 0.001 Ʋ Leukocytes (x 10³/μL) 15.63 (± 5.43) 14.01 (±4.4) 0.077 t Neutrophils (%) 74 (58.64 – 89.36) 73.45 (59.6 – 87.3) 0.380 Ʋ Bands (%) 10 (3- 15.8) 3 (0- 7) < 0.001 Ʋ Sodium (mEq/L) 133.23 (± 2.83) 138.08 (± 3.63) 0.039 t Ultrasonographic diameter of the appendix (mm) 12 (8-16) 8 (4.5-11.5) 0.173 Ʋ *Body mass index, Ʋ Mann-Whitney U, Student's tt. Data are expressed as mean ± standard deviation for variables with normal distribution, and as median (interquartile range) for those with non-normal distribution, determined using the Kolmogorov–Smirnov test. Table 3 Bivariate analysis of factors associated with complicated appendicitis in the pediatric population Variable OR 95% CI p Presence of fever 3.3 1.35-8.34 0.032 Absence of McBurney's sign with high clinical suspicion 1.23 0.45 – 3.38 0.878 Nausea or vomiting 1.77 0.75 – 4.16 0.269 Diarrhea 2.11 0.91 – 4.87 0.124 Presence of appendicolith on USG 3.93 1.41 –10.92 0.002 Onset of abdominal pain prior to first assessment 24 Hours 2.19 1.01 – 4.74 0.072 Age (years) 0.92 0.81 – 1.04 0.076 Hours since onset of pain 1.58 1.14- 2.20 0.001 Leukocytes (x10³/μL) 1.05 0.99 - 1.12 0.077 Bands (%) 1.22 1.09 – 1.36 0.001 Sodium (mEq/L) 0.75 0.60 – 0.92 0.039 Appendicular diameter (mm) 1.18 0.98 – 1.42 0.173 Analysis using binary logistic regression. Crude odds ratios (ORs), 95% confidence intervals (CIs), and p values are reported. Table 4 Multivariate logistic regression model for predictors of complicated appendicitis Age (years) 0.92 0.81 – 1.04 0.18 Leukocytes (x10³/μL) 1.05 0.99 – 1.12 0.09 Bands (%) 1.22 1.09 – 1.36 0.001 Sodium (mEq/L) 0.75 0.60 – 0.92 0.004 Appendicular diameter (mm) 1.18 0.98 – 1.42 0.08 Fever (present) 5.58 1.89 – 16.42 0.002 Appendicolith (present) 1.42 1.10 – 1.83 0.006 Model fitted with enter method, Nagelkerke R²: 0.043, Hosmer–Lemeshow goodness-of-fit test: χ² = 4.11 p = 0.767 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7187653","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":491893611,"identity":"803cca0c-66fc-4883-8bfc-ef052e518ef8","order_by":0,"name":"Stéphane Emile Montcharmont Sada","email":"","orcid":"","institution":"Universidad La Salle","correspondingAuthor":false,"prefix":"","firstName":"Stéphane","middleName":"Emile Montcharmont","lastName":"Sada","suffix":""},{"id":491893612,"identity":"6bf3988a-8655-4765-9cb6-eb1f5712d0e9","order_by":1,"name":"Francisco M Bravo Rojas","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA2UlEQVRIiWNgGAWjYBAC9gYGNjCDn735AJCSkCGohecAVItkz7EEkBYe4rUY3MgxAAsQ1sJ++NjjiprDcgZnznx+daPGgoeB/fDRDXi18KSlG545dthY8njvNuucY0CH8aSl3cCnxV6Cx0yygS0tse/M2W3GOWxALUARvFp4wFr+pSU23Mh5Zpzzj1gtjW02iRNu5DA/zm0jRgvIL419NsbAQDZjzu2T4GEj5BdQiD1s+CYhB4zKx59zvtUBGYeP4dWCDNgkwCSxykGA+QMpqkfBKBgFo2DkAACpCEW/VWgaBwAAAABJRU5ErkJggg==","orcid":"","institution":"Universidad La Salle","correspondingAuthor":true,"prefix":"","firstName":"Francisco","middleName":"M Bravo","lastName":"Rojas","suffix":""},{"id":491893613,"identity":"bf6971fe-8b34-406d-9c26-1542f2948424","order_by":2,"name":"María Riba Olea","email":"","orcid":"","institution":"Universidad La Salle","correspondingAuthor":false,"prefix":"","firstName":"María","middleName":"Riba","lastName":"Olea","suffix":""},{"id":491893615,"identity":"54b033d4-8ee4-4a03-86c5-814c965244b4","order_by":3,"name":"Cristian Puerta","email":"","orcid":"","institution":"University of California, San Diego","correspondingAuthor":false,"prefix":"","firstName":"Cristian","middleName":"","lastName":"Puerta","suffix":""},{"id":491893616,"identity":"ccf40db7-5b66-45d9-8030-acbb7a50a3f0","order_by":4,"name":"Mario E Rendón Macías","email":"","orcid":"","institution":"Panamerican University","correspondingAuthor":false,"prefix":"","firstName":"Mario","middleName":"E Rendón","lastName":"Macías","suffix":""},{"id":491893619,"identity":"84aadeb5-c9ae-48b3-8787-4ffe8b6f2f43","order_by":5,"name":"Samuel Fernández Valiñas","email":"","orcid":"","institution":"Hospital Español","correspondingAuthor":false,"prefix":"","firstName":"Samuel","middleName":"Fernández","lastName":"Valiñas","suffix":""},{"id":491893621,"identity":"fe4494cc-b6fb-4d49-88cb-f417bf2f2764","order_by":6,"name":"Horacio Silva Ramírez","email":"","orcid":"","institution":"Hospital Español","correspondingAuthor":false,"prefix":"","firstName":"Horacio","middleName":"Silva","lastName":"Ramírez","suffix":""}],"badges":[],"createdAt":"2025-07-22 13:38:23","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7187653/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7187653/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":87900771,"identity":"ba45e601-78f9-4402-8852-7baa6df45063","added_by":"auto","created_at":"2025-07-30 08:12:16","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":122476,"visible":true,"origin":"","legend":"\u003cp\u003eIntraoperative distribution of appendicitis. Uncomplicated forms (edematous and suppurative) accounted for 71.6%, while complicated forms (gangrenous and perforated) represented 28.4% of cases.\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-7187653/v1/b5b5b0b429a98b7aa717fbc5.png"},{"id":88544388,"identity":"84e72990-66ac-4a3b-8918-d5e177e6fb57","added_by":"auto","created_at":"2025-08-07 14:17:04","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":670738,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7187653/v1/07dccb87-7892-4e10-8f71-1dde4d4ecefa.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Clinical, Laboratory and Imaging Predictors of Complicated Appendicitis in Children: A Multivariate Analysis","fulltext":[{"header":"Introduction","content":"\u003cp\u003eAcute appendicitis is the most common abdominal surgical emergency in the pediatric population and continues to be a significant cause of morbidity, particularly when it progresses to complicated forms (1,2). The pathophysiology often begins with obstruction of the appendiceal lumen, typically due to appendicoliths or lymphoid hyperplasia, resulting in secretory accumulation, increased intraluminal pressure, vascular compromise, and ischemia, eventually leading to bacterial invasion, necrosis, and perforation (3,4). In advanced stages, the inflammatory process may result in localized or generalized peritonitis, often accompanied by systemic manifestations such as hyponatremia, which is thought to the arise from inflammatory mediator release and increased capillary permeability (5).\u003c/p\u003e\u003cp\u003eDespite advancements in diagnostics and treatment, the rate of complicated appendicitis (CA) remains high, especially in children under five years of age, with reported rates up to 80% (6,7). Complicated cases are associated with longer hospitalizations, increased antibiotic use, and greater postoperative complications (8,9). Early diagnosis remains challenging due to nonspecific symptoms, limited communication in pediatric patients, and variable clinical progression (8,10).\u003c/p\u003e\u003cp\u003eSeveral tools have been proposed to support clinical judgment, including the Pediatric Appendicitis Score (PAS), which incorporates clinical and laboratory data with variable sensitivity and specificity (11,12). A high PAS may indicate increased risk, particularly when associated with imaging findings such as increased appendiceal diameter or elevated C-reactive protein levels (CRP) (7,13). Clinical features such as symptom duration over 24 hours, persistent fever, the presence of an appendicolith on imaging, leukocytosis, neutrophilia, and bandemina have been linked to increased risk of complication rates (6,14,15).\u003c/p\u003e\u003cp\u003eAmong these, hyponatremia has gained attention as a marker of systemic inflammation, with consistent associations reported in multiple studies and meta-analyses (14,15). These findings have prompted the development of prediction models that integrate clinical, laboratory, and imaging variables to enhance early detection of complicated cases.\u003c/p\u003e\u003cp\u003eHowever, significant heterogeneity persists across studies, limiting generalizability. This study aims to identify clinical, laboratory, and imaging factors associated with complicated appendicitis in a Mexican pediatric cohort.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003e This cross-sectional study was conducted in a cohort of pediatric patients under 18 years of age with a histopathological diagnosis of acute appendicitis, treated at a private tertiary care hospital in Mexico City between January 2019 and March 2024. Patients were included if they had complete medical records, a confirmed histopathological diagnosis of appendicitis, and detailed records including clinical, laboratory, and imaging data at the time of admission. Cases with alternative surgical diagnoses or incomplete records were excluded.\u003c/p\u003e\u003cp\u003eThe final sample included 134 patients. The dependent variable was the presence of complicated appendicitis, defined as gangrenous, perforated, or associated with abscess formation as documented during surgery. Non-complicated cases included edematous or suppurative appendicitis without evidence of necrosis or perforation.\u003c/p\u003e\u003cp\u003eStatistical analysis was performed using IBM SPSS Statistics version 28.0. Descriptive analysis were reported as absolute frequencies and percentages for categorical variables, and as means\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviations or means with interquartile ranges (IQR) for continuous variables, according to their distribution assessed by the Kolmogorov\u0026ndash;Smirnov test.\u003c/p\u003e\u003cp\u003eGroup comparisons were conducted using chi-square or Fisher\u0026rsquo;s exact test for categorical variables, and Student\u0026rsquo;s t-test or Mann\u0026ndash;Whitney U for quantitative variables, as appropriate. Bivariate logistic regression was used to estimate the association between independent variables and the presence of complicated appendicitis, reporting odds ratios (OR) with 95% confidence intervals (95% CI).\u003c/p\u003e\u003cp\u003eVariables with a p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.20 in the bivariate analysis were included into a multivariate binary logistic regression model using the Enter method. Statistical significance was set at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05. Model fit was assessed using the Hosmer\u0026ndash;Lemeshow test, and the Nagelkerke R-squared coefficient was reported.\u003c/p\u003e\u003cp\u003e The study protocol was reviewed and approved by the Institutional Ethics Committee. Given its retrospective nature, informed consent was not required. No missing data were identified for the variables included in the multivariate analysis.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 134 patients with a histopathological diagnosis of acute appendicitis were included. Among them, 38 cases (28.3%) were classified as complicated appendicitis, defined as gangrenous, perforated, or with abscess formation, while the remaining 96 cases (71.6%) were classified as non-complicated apendicitis, including edematous or suppurative appendicitis forks without evidence of perforation or necrosis. All cases had complete clinical records, including documentation of clinical, laboratory, and imaging data at the time of admission.\u003c/p\u003e\n\u003cp\u003eWhen comparing categorical clinical characteristics between the two groups (table 1), fever was significantly more common in the complicated group (94.7%) than non-complicated group (28.1%; p \u0026lt; 0.001). \u0026nbsp; McBurney\u0026apos;s sign was more commonly observed in the complicated group (84.2%) compared to the non-complicated group (81.25%; p = 0.023). Nausea and/or vomiting were more frequent in non-complicated cases (64.6%) than in complicated ones (21.6%; p \u0026lt; 0.001). Diarrhea was reported in 19.7% of the non-complicated cases and 34.2% of the complicated cases, though this difference did not reach statistical significance (p = 0.058). Appendicoliths were more frequently identified in patients with complicated appendicitis (26.3%) than in those with non-complicated forms (8.3%; p = 0.006), and phlegmon was observed exclusively in the complicated group (23.7%; p = 0.041).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSymptom duration prior to medical consultation also differed significantly: in the complicated group, 21.1% presented within 12 hours, 31.6% between 12 and 24 hours, and 47.4% after 24 hours. In contrast, among non-complicated cases, 52.1% presented within 12 hours, 18.7% between 12-24 hours, and 29.1% after 24 hours (p = 0.005). There were no significant differences between groups regarding the surgical approach (p = 0.245).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIntraoperative classification of appendicitis types revealed that 52 out of 96 non-complicated cases (54.1%) were edematous and 45.8% suppurative. Among complicated cases, 7 (18.4%) were gangrenous and 31 (81.5%) perforated (Figure 1).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAnalysis of quantitative variables (Table 2) \u0026nbsp;showed significant higher band counts in the complicated group (median 10%, IQR 3\u0026ndash;15.8) compared to non-complicated cases (median 3%, IQR 0\u0026ndash;7; p \u0026lt; 0.001). Serum sodium levels were lower in the complicated group (mean 133.2 \u0026plusmn; 2.8 mEq/L) compared to the non-complicated group (mean 138.1 \u0026plusmn; 3.6 mEq/L, p = 0.039). Appendiceal diameter measured on ultrasound was greater in the complicated group (median 12 mm, IQR 8\u0026ndash;16) versus the non-complicated group (median 8 mm, IQR 4.5\u0026ndash;11.5), though the difference was not significant (p = 0.173). Total leukocyte count was higher in complicated cases (mean 15.6 \u0026plusmn; 5.4 x10\u0026sup3;/\u0026mu;L) than in the non-complicated group (mean 14.0 \u0026plusmn; 4.4 x10\u0026sup3;/\u0026mu;L; p = 0.077). Mean patient age was slightly lower in the complicated group (9.37 \u0026plusmn; 4.54 years) when compared to non-complicated patients (10.75 \u0026plusmn; 3.81 years; p = 0.076). No significant difference was found in neutrophil percentage between groups (p = 0.380).\u003c/p\u003e\n\u003cp\u003eIn the bivariate analysis (Table 3), fever at admission was associated with a more than threefold increase in the likelihood of complicated appendicitis (OR 3.30, 95% CI: 1.35-8.34; p = 0.032). Appendicolith presence was also significantly associated with complications (OR 1.42, 95% CI: 1.10-1.83; p = 0.006). Each 1% in band cell percentage increased the odds of complication by 22% (OR 1.22, 95% CI: 1.09-1.36; p \u0026lt; 0.001). Conversely, each 1 mEq/L increase in serum sodium was associated with a 25% reduction in complication risk (OR 0.75, 95% CI: 0.60-0.92; p = 0.039).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOther variables showed a borderline associations.. Higher leukocyte count at admission was associated with a 5% increase in the risk of complicated appendicitis for every additional 1,000 cells/\u0026mu;L (OR 1.05, 95% CI: 0.99\u0026ndash;1.12, p = 0.077), younger age at diagnosis also appeared related to higher risk, with an 8% decrease in the likelihood of complicated appendicitis per additional year of age (OR 0.92, 95% CI: 0.81\u0026ndash;1.04, p = 0.076).\u003c/p\u003e\n\u003cp\u003eA progressive association was also identified between symptom duration and the likelihood of complication. Compared to patients who consulted within 12 hours of pain onset, those who sought care between 12 and 24 hours had twice the likelihood of presenting with complicated appendicitis (OR 2.00, 95% CI: 0.85\u0026ndash;4.70, p = 0.169), while those who presented after 24 hours showed a 119% increase in that likelihood (OR 2.19, 95% CI: 1.01\u0026ndash;4.74, p = 0.072).\u003c/p\u003e\n\u003cp\u003eThe multivariate logistic regression model was (Table 4) constructed including variables with a p \u0026lt; \u0026nbsp;0.20 in the bivariate analysis. The final model included: age, leukocyte count, band count percentage, serum sodium level, appendiceal diameter, presence of fever, and presence of appendicolith. In this model, band count percentage (OR 1.22, 95% CI: 1.09\u0026ndash;1.36, p = 0.001), sodium level (OR 0.75, 95% CI: 0.60\u0026ndash;0.92, p = 0.004), presence of fever (OR 5.58, 95% CI: 1.89\u0026ndash;16.42, p = 0.002), and presence of appendicolith (OR 1.42, 95% CI: 1.10\u0026ndash;1.83, p = 0.006) remained significantly associated factors. The model showed good fit according to the Hosmer\u0026ndash;Lemeshow test (\u0026chi;\u0026sup2; = 4.11, p = 0.767), indicating that no significant differences between observed and expected frequencies. This suggests the model achieves a coherent representation of the data without overfitting, and the observed distribution of complicated appendicitis is consistent with the predicted distribution based on the included variables.\u003c/p\u003e\n\u003cp\u003eMoreover, the Nagelkerke R-squared coefficient was R\u0026sup2; = 0.043, indicating that the model explained approximately 4.3% of the total variability observed in the occurrence of complicated appendicitis. While this reflects modest explanatory power, it is important to note that in clinical studies involving multiple factors, low R\u0026sup2; values are common and do not necessarily invalidate the model\u0026apos;s utility\u0026mdash;particularly when the retained variables are statistically significant and clinically plausible.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eComplicated acute appendicitis, encompassing perforation, gangrene, or abscess, represents approximately 15\u0026ndash;30% of pediatric cases and is associated with higher morbidity, risk of abscess formation, longer hospital stays, and increased healthcare costs (16,17). Early recognition of predictive factors is therefore critical to optimize management, including timely antibiotics, surgery, or drainage. In the last decade, various predictors have been proposed; our study focused on clinical and paraclinical variables with physiological plausibility. In our cohort, four factors were significantly associated with complicated appendicitis: fever at admission, hyponatremia, elevated band count percentage, and the presence of an appendicolith.\u003c/p\u003e\n\u003cp\u003eFever is a well-established \u0026nbsp;marker of systemic inflammation and a potential predictor of complicated appendicitis. Our findings partially support this concept, as complicated cases present more frequently with fever. Studies such as Zvizdić et al. (2021) have identified fever as an independent predictor of perforation (OR ~3.4) (18). From a mechanistic perspective, high fever reflects a raise in the hypothalamic set point (19) by cytokine-mediated immune activation (IL-1, IL-6, TNF-\u0026alpha;), in the setting of transmural infection and peritonitis. However, some studies, Roushan et al. (2021), reported no significant difference in fever incidence between children with simple and complicated appendicitis (16.6% vs. 19.7%, p = 1.0) (14). Therefore, absence of fever does not rule out complication, especially in young children or those previously treated with antipyretics. Thus, fever should be interpreted with caution and in conjunction with other findings.\u003c/p\u003e\n\u003cp\u003eSystemic inflammatory response is typically reflected in neutrophilic leukocytosis. In our cohort, patients with complicated appendicitis had higher average white blood cell counts and band percentages. This finding aligns with studies by Zvizdić et al. (18) and Howell et al. (17), which reported associations between leukocytosis, left shift, and perforation. However, Roushan et al. (14) found no significant difference in leukocyte counts between simple and complicated forms, highlighting the limited specificity of this marker when interpreted in isolation. Confounding factors such as dehydration, prior treatment, or timing of blood sampling may affect these values. Nevertheless, marked bandemia remains a relevant warning sign, as described in prior series (\u0026gt;20% bands) (17).\u003c/p\u003e\n\u003cp\u003eOne of the most consistent findings was hyponatremia, which was significantly associated with complicated appendicitis. This association is consistent with multiple retrospective, prospective, and meta-analytic studies (15,20,21). For example, Zhan et al. (2022) and Anand et al. (2022) described an approximate 3 mEq/L difference in sodium levels between complicated and non-complicated cases. Pogorelić et al. (2020) and Salam et al. (2023) reported mean sodium values of 132\u0026ndash;133 mEq/L in complicated cases versus 138\u0026ndash;139 mEq/L in non-complicated ones (22,23). Hyponatremia has been linked to non-osmotic secretion of antidiuretic hormone (ADH) induced by cytokines such as IL-6, resulting in free water retention and serum sodium dilution (24). Additionally, insensible fluid losses due to fever or tachypnea may contribute to this finding (25). Altogether, these data support the clinical value of low sodium as an early marker of disease severity. A sodium level \u0026lt;135 mEq/L in a child with suspected appendicitis should raise concern for perforation or abscess.\u003c/p\u003e\n\u003cp\u003eThe presence of an appendicolith was another significant factor associated with complications. Its pathophysiological in the role of luminal obstruction and mural necrosis is well established (3,4). Yoon et al. (2018) and Khan et al. (2019) demonstrated a higher risk of perforation in the presence of a fecalith (26,27). Furthermore, the presence of an appendicolith has been linked to a higher failure rate of nonoperative management (28,29), prompting suggestions to use it as an exclusion criterion for conservative treatment. In our study, the odds ratio for appendicolith decreased after adjustment for other variables, suggesting collinearity with fever or bandemia. Nevertheless, its statistical significance remained, reaffirming its predictive value.\u003c/p\u003e\n\u003cp\u003eTaken together, these factors outline that a clinical, biochemical, and imaging profile can assist clinicians from the time of admission. Our findings enable early identification of children at higher risk for complications, facilitating more timely surgical decisions. We recommend incorporating these variables into scoring systems or management algorithms. Fever, bandemia, hyponatremia, and appendicolith should be considered for early risk stratification and to optimize intervention timing, reducing the likelihood of progression to generalized peritonitis and its sequelae (6,17,30).\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eIn this pediatric cohort, fever at admission, hyponatremia, elevated band cell percentage, and the presence of an appendicolith were significantly associated with complicated forms of appendicitis. This findings highlight the clinical value of simple and readily accessible variables available at the time of hospital admission for early risk stratification. Timely recognition of these factors may enhance both diagnostic accuracy and therapeutic decision-making in pediatric settings. Our results support the development of integrated predictive tools that combine clinical, laboratory, and imaging data at presentation. Such tools may facilitate earlier identification of high-risk cases in emergency departments and contribute to more effective initial management protocols.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eFunding. No funding was received for the conduct of this study.\u003c/p\u003e\n\u003cp\u003eConflict of interest. The authors declare that they have no conflicts of interest that could have influenced the results or interpretation of the study.\u003c/p\u003e\n\u003cp\u003eEthics approval and consent to participate. The study was approved by the relevant ethics committee.\u003c/p\u003e\n\u003cp\u003eConsent for publication. Not applicable.\u003c/p\u003e\n\u003cp\u003eData availability. Not applicable.\u003c/p\u003e\n\u003cp\u003eMaterials availability. Not applicable.\u003c/p\u003e\n\u003cp\u003eCode availability. No custom code was used in this study.\u003c/p\u003e\n\u003cp\u003eAuthor contributions. All authors made substantial contributions to the conception and design of the study, data analysis, and manuscript writing. All authors reviewed and approved the final version of the manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAlFraih YS, AlMutawa R. What do you do with a normal appearing appendix?: A national study of Pediatric Surgeons. Saudi Med J. 2024 Sep;45(9):929\u0026ndash;34. DOI: 10.15537/smj.2024.45.9.20240207\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKettler A, Claudius I. Pediatric High-Risk Conditions. Emerg Med Clin North Am. 2025 Feb;43(1):41\u0026ndash;56. DOI: 10.1016/j.emc.2024.05.023\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMuhammad W, Cecily FWang. StatPearls [Internet]. 2025. (Treasure Island (FL): StatPearls). Available from: https://www.ncbi.nlm.nih.gov/books/NBK441864/\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRothrock SG, Pagane J. Acute appendicitis in children: Emergency department diagnosis and management. Ann Emerg Med. 2000 Jul;36(1):39\u0026ndash;51. DOI: 10.1067/mem.2000.105658\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eReismann M. A concise pathophysiological model of acute appendicitis against the background of the COVID-19 pandemic. Front Pediatr [Internet]. 2022 Oct 13 [cited 2025 Jul 10];10. DOI: 10.3389/fped.2022.908524\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLi D, Zhang Z, Wan J, Zhao J, Wei G, Pan W, et al. Clinical features and perforation predictors of appendicitis in infants and toddlers under 3: A retrospective two-center study. Sci Rep. 2025 Apr 24;15(1):14338. 1 DOI 10.1038/s41598-025-99293-1\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFeng W, Zhao XF, Li MM, Cui HL. A clinical prediction model for complicated appendicitis in children younger than five years of age. BMC Pediatr. 2020 Dec;20(1):401. DOI: 10.1186/s12887-020-02286-4\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAzmeraw M, Abate BB, Temesgen D, Feleke SF, Haile RN, Abate MD, et al. Complicated appendicitis and associated risk factors among children. BMC Pediatr. 2025 Apr 29;25(1):336. DOI: 10.1186/s12887-025-05447-5\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePerez Otero S, Metzger JW, Choi BH, Ramaraj A, Tashiro J, Kuenzler KA, et al. It\u0026rsquo;s time to deconstruct treatment-failure: A randomized controlled trial of nonoperative management of uncomplicated pediatric appendicitis with antibiotics alone. J Pediatr Surg. 2022 Jan;57(1):56\u0026ndash;62. DOI: 10.1016/j.jpedsurg.2021.09.024\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eJu JJ, Zhang T, Cheng Y, Zhou YL, Qi SQ, Zhang ZQ, et al. Risk factors for acute complicated appendicitis in children aged three years and younger. BMC Pediatr. 2024 Jul 27;24(1):484. DOI: 10.1186/s12887-024-04959-w\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBar\u0026oacute;n-M\u0026eacute;ndez LE, Acosta-Su\u0026aacute;rez S, Tinoco-Guzm\u0026aacute;n NJ, Robayo-Garc\u0026iacute;a JT, Porras-Luengas ML. Utilidad del Pediatric Appendicitis Score (PAS) para el diagn\u0026oacute;stico de apendicitis aguda en pacientes pedi\u0026aacute;tricos. Rev Colomb Cir [Internet]. 2025 Jan 24 [cited 2025 Jul 5]; Available from: https://www.revistacirugia.org/index.php/cirugia/article/view/2726 DOI: 10.30944/20117582.2726\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eOrtiz-Ley JD, Cano-Rodr\u0026iacute;guez MT, Cort\u0026eacute;s-Salim P, G\u0026oacute;mez-Coles A, Sosa-Bustamante GP. Inflamatory indexes predictors of complicated acute apendicitis in children. Vol. 61 Supl. 2. Rev Med Inst Mex Seguro Soc.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAguilar-Andino D, Licona Rivera TS, Osejo Quan JA, Carranza Linares RJ, Molina Soto MA, Alas-Pineda C. Apendicitis aguda complicada en pacientes pedi\u0026aacute;tricos con antecedentes de \u0026ldquo;empacho\u0026rdquo; y manipulaci\u0026oacute;n abdominal: serie de casos. Andes Pediatr. 2021 Feb 20;92(1):86. DOI: 10.32641/andespediatr.v92i1.3352\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRoushan CP, Sah GK, Mandal P, Koirala DP, Dahal GR. Factors predictive of complicated appendicitis in children. Int Surg J. 2021 Nov 26;8(12):3511. DOI: 10.18203/2349-2902.isj20214739\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eZhan W, Deng W, Liu Y, Feng S. Hyponatremia as a predictor of complicated appendicitis in children: A systematic review and meta-analysis. Asian J Surg. 2022 Oct;45(10):2009\u0026ndash;11. DOI: 10.1016/j.asjsur.2022.04.058\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBhattacharya J, Silver EJ, Blumfield E, Jan DM, Herold BC, Goldman DL. Clinical, Laboratory and Radiographic Features Associated With Prolonged Hospitalization in Children With Complicated Appendicitis. Front Pediatr [Internet]. 2022 Apr 6;10. DOI: 10.3389/fped.2022.828748\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHowell EC, Dubina ED, Lee SL. Perforation risk in pediatric appendicitis: assessment and management. Pediatr Health Med Ther. 2018 Oct;Volume 9:135\u0026ndash;45. DOI: 10.2147/PHMT.S155302\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eZvizdic Z, Golos AD, Milisic E, Jonuzi A, Zvizdic D, Glamoclija U, et al. The predictors of perforated appendicitis in the pediatric emergency department: A retrospective observational cohort study. Am J Emerg Med. 2021 Nov;49:249\u0026ndash;52.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBinboga S, Isiksacan N, Binboga E, Kasapoglu P, Surek A, Karabulut M. Diagnostic Value of Serum Cytokines in Predicting a Complicated Acute Appendicitis. An Acad Bras Ci\u0026ecirc;nc [Internet]. 2022 [cited 2025 Jul 11];94(2). DOI: 10.1590/0001-3765202220201947\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGiannis D, Matenoglou E, Moris D. Hyponatremia as a marker of complicated appendicitis: A systematic review. The Surgeon. 2020 Oct;18(5):295\u0026ndash;304. DOI: 10.1016/j.surge.2020.01.002\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAnand S, Krishnan N, Birley J, Tintor G, Bajpai M, Pogorelić Z. Hyponatremia\u0026mdash;A New Diagnostic Marker for Complicated Acute Appendicitis in Children: A Systematic Review and Meta-Analysis. Children. 2022 Jul 18;9(7):1070. DOI: 10.3390/children9071070\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePogorelić Z, Lukšić B, Ninčević S, Lukšić B, Polašek O. Hyponatremia as a predictor of perforated acute appendicitis in pediatric population: A prospective study. J Pediatr Surg. 2021 Oct;56(10):1816\u0026ndash;21. DOI: 10.1016/j.jpedsurg.2020.09.066\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSalman \u0026Ouml;nemli C, Evren Şahin K, Atacan \u0026Ouml;. Assessment of the Prognostic Power of Preoperative Laboratory Biomarkers in Predicting Pediatric Complicated Appendicitis and the Outcomes of the Relevant Surgical Intervention. J Pediatr Res. 2023 Sep 1;10(3):173\u0026ndash;81. DOI: 10.4274/jpr.galenos.2023.37630\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eOzdemir DB, Karayigit A, Dizen H, Unal B. Role of hyponatremia in differentiating complicated appendicitis from uncomplicated appendicitis: a comparative study. 2022. 26(8057\u0026ndash;8063). DOI 10.26355/eurrev_202211_30159 DOI: 10.26355/eurrev_202211_30159\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFleisher G, Ludwig S. Insensible water loss in febrile or tachypneic pediatric patients. [Internet]. Medscape; 2022. Available from: https://emedicine.medscape.com/article/936511-overview\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eYoon HM, Kim JH, Lee JS, Ryu JM, Kim DY, Lee JY. Pediatric appendicitis with appendicolith often presents with prolonged abdominal pain and a high risk of perforation. World J Pediatr. 2018 Apr;14(2):184\u0026ndash;90. DOI 10.1007/s12519-018-0128-8. DOI: 10.1007/s12519-018-0128-8\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKhan MS, Siddiqui MTH, Shahzad N, Haider A, Chaudhry MBH, Alvi R. Factors Associated with Complicated Appendicitis: View from a Low-middle Income Country. Cureus [Internet]. 2019 May 28 [cited 2025 Jul 10]; DOI 10.7759/cureus.4765\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBrucchi F, Filisetti C, Luconi E, Fugazzola P, Cattaneo D, Ansaloni L, et al. Non-operative management of uncomplicated appendicitis in children, why not? A meta-analysis of randomized controlled trials. World J Emerg Surg [Internet]. 2025 Mar 25 [cited 2025 Jul 10];20(1). DOI 10.1186/s13017-025-00584-9\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMahida JB, Lodwick DL, Nacion KM, Sulkowski JP, Leonhart KL, Cooper JN, et al. High failure rate of nonoperative management of acute appendicitis with an appendicolith in children. J Pediatr Surg. 2016 Jun;51(6):908\u0026ndash;11. DOI 10.1016/j.jpedsurg.2016.02.056\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKum HJ, Gang S, Kim DY. The Feasibility of Nonoperative Management (NOM) in Pediatric Acute Appendicitis in the Era of Coronavirus Disease-2019 (COVID-19). Adv Pediatr Surg. 2023;29(2):65. DOI 10.13029/aps.2023.29.2.65Annexes\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"586\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"7\" style=\"width: 586px;\"\u003e\n \u003cp\u003eTable 1.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"7\" style=\"width: 586px;\"\u003e\n \u003cp\u003eComparison of categorical clinical variables between patients with complicated and uncomplicated appendicitis.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" rowspan=\"2\" style=\"width: 226px;\"\u003e\n \u003cp\u003eFeature\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 142px;\"\u003e\n \u003cp\u003eComplicated*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 142px;\"\u003e\n \u003cp\u003eNot complicated\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cem\u003ep+\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cem\u003en (38)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cem\u003e%\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cem\u003en (96)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 226px;\"\u003e\n \u003cp\u003eSex\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 28px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 198px;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e63.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e63\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e65.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.787\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 28px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 198px;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e36.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e34.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 226px;\"\u003e\n \u003cp\u003eType of surgery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.245\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 28px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eOpen appendectomy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e36.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e46\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e47.91\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 28px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eLaparoscopic appendectomy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e63.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e52\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 226px;\"\u003e\n \u003cp\u003eSymptoms\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 28px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 198px;\"\u003e\n \u003cp\u003eFever\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e94.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e28.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.041\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 28px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 198px;\"\u003e\n \u003cp\u003eMcBurney\u0026apos;s sign\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e84.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e78\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e81.25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.023\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 28px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 198px;\"\u003e\n \u003cp\u003eNausea/Vomiting\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e21.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e62\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e64.58\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e0.190\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 28px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 198px;\"\u003e\n \u003cp\u003eDiarrhea\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e34.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e19.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.058\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 226px;\"\u003e\n \u003cp\u003eUltrasonographic findings\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 28px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 198px;\"\u003e\n \u003cp\u003ePresence of appendicolith\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e26.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e8.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.006\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 28px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 198px;\"\u003e\n \u003cp\u003ePresence of plastron\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e23.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.041ᵩ\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 226px;\"\u003e\n \u003cp\u003eHours until care\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 28px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 198px;\"\u003e\n \u003cp\u003e\u0026lt;12 hours#\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e52\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.005\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 28px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 198px;\"\u003e\n \u003cp\u003e12-24 hours\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e31.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e18.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 28px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 198px;\"\u003e\n \u003cp\u003e\u0026gt;24 hours\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e47.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e29.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"7\" style=\"width: 586px;\"\u003e\n \u003cp\u003e\u003cem\u003e*\u0026nbsp;Complicated appendicitis defined as the presence of surgical findings of perforation or gangrenous appendicitis during the procedure, + chi-square (\u0026chi;\u0026sup2;)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u003csup\u003e#\u003c/sup\u003e\u003c/em\u003e\u003cem\u003ereference category,\u003c/em\u003e\u003cstrong\u003e\u003csup\u003eᵩ\u003c/sup\u003e\u003c/strong\u003e\u003cem\u003eFisher\u0026apos;s exact test\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"597\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" valign=\"top\" style=\"width: 597px;\"\u003e\n \u003cp\u003eTable 2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" valign=\"top\" style=\"width: 597px;\"\u003e\n \u003cp\u003eComparison of quantitative variables between patients with complicated and uncomplicated appendicitis\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 220px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 144px;\"\u003e\n \u003cp\u003eComplicated\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 153px;\"\u003e\n \u003cp\u003eNot complicated\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 80px;\"\u003e\n \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 220px;\"\u003e\n \u003cp\u003eAge (years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 144px;\"\u003e\n \u003cp\u003e9.37 (\u0026plusmn;4.54)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 153px;\"\u003e\n \u003cp\u003e10.75 (\u0026plusmn;3.81)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 80px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.076 t\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 220px;\"\u003e\n \u003cp\u003eBMI* (kg/m\u0026sup2;)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 144px;\"\u003e\n \u003cp\u003e17.89 (\u0026plusmn; 3.75)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 153px;\"\u003e\n \u003cp\u003e18.76 (\u0026plusmn; 3.74)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 80px;\"\u003e\n \u003cp\u003e0.227 t\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 220px;\"\u003e\n \u003cp\u003eHours elapsed since onset of abdominal pain\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 144px;\"\u003e\n \u003cp\u003e23 (15.25-43)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 153px;\"\u003e\n \u003cp\u003e11.5 (7-24)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 80px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.001 Ʋ\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 220px;\"\u003e\n \u003cp\u003eDays of hospital stay\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 144px;\"\u003e\n \u003cp\u003e5 (1-9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 153px;\"\u003e\n \u003cp\u003e3 (1-5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 80px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt; 0.001 Ʋ\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 220px;\"\u003e\n \u003cp\u003eLeukocytes (x 10\u0026sup3;/\u0026mu;L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 144px;\"\u003e\n \u003cp\u003e15.63 (\u0026plusmn; 5.43)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 153px;\"\u003e\n \u003cp\u003e14.01 (\u0026plusmn;4.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 80px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.077\u003c/strong\u003e\u003cem\u003e\u003csup\u003et\u003c/sup\u003e\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 220px;\"\u003e\n \u003cp\u003eNeutrophils (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 144px;\"\u003e\n \u003cp\u003e74 (58.64 \u0026ndash; 89.36)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 153px;\"\u003e\n \u003cp\u003e73.45 (59.6 \u0026ndash; 87.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 80px;\"\u003e\n \u003cp\u003e0.380 Ʋ\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 220px;\"\u003e\n \u003cp\u003eBands (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 144px;\"\u003e\n \u003cp\u003e10 (3- 15.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 153px;\"\u003e\n \u003cp\u003e3 (0- 7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 80px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt; 0.001 Ʋ\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 220px;\"\u003e\n \u003cp\u003eSodium (mEq/L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 144px;\"\u003e\n \u003cp\u003e133.23 (\u0026plusmn; 2.83)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 153px;\"\u003e\n \u003cp\u003e138.08 (\u0026plusmn; 3.63)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 80px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.039\u003c/strong\u003e\u003cem\u003e\u003csup\u003et\u003c/sup\u003e\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 220px;\"\u003e\n \u003cp\u003eUltrasonographic diameter of the appendix (mm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 144px;\"\u003e\n \u003cp\u003e12 (8-16)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 153px;\"\u003e\n \u003cp\u003e8 (4.5-11.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 80px;\"\u003e\n \u003cp\u003e0.173 Ʋ\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" valign=\"top\" style=\"width: 597px;\"\u003e\n \u003cp\u003e\u003cem\u003e*Body mass index, Ʋ Mann-Whitney U, Student\u0026apos;s tt.\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eData are expressed as mean \u0026plusmn; standard deviation for variables with normal distribution, and as median (interquartile range) for those with non-normal distribution, determined using the Kolmogorov\u0026ndash;Smirnov test.\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"586\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\" style=\"width: 586px;\"\u003e\n \u003cp\u003eTable 3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\" style=\"width: 586px;\"\u003e\n \u003cp\u003eBivariate analysis of factors associated with complicated appendicitis in the pediatric population\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 264px;\"\u003e\n \u003cp\u003eVariable\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003eOR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e95% CI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 264px;\"\u003ePresence of fever\u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e3.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e1.35-8.34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.032\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 264px;\"\u003e\n \u003cp\u003eAbsence of McBurney\u0026apos;s sign with high clinical suspicion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e1.23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e0.45 \u0026ndash; 3.38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e0.878\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 264px;\"\u003e\n \u003cp\u003eNausea or vomiting\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e1.77\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e0.75 \u0026ndash; 4.16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e0.269\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 264px;\"\u003e\n \u003cp\u003eDiarrhea\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e2.11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e0.91 \u0026ndash; 4.87\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e0.124\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 264px;\"\u003e\n \u003cp\u003ePresence of appendicolith on USG\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e3.93\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e1.41 \u0026ndash;10.92\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.002\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 264px;\"\u003e\n \u003cp\u003eOnset of abdominal pain prior to first assessment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 198px;\"\u003e\n \u003cp\u003e\u0026lt;12 Hours\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e0.25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e0.10 \u0026ndash; 0.59\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e0.002\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 198px;\"\u003e\n \u003cp\u003e12\u0026ndash;24 Hours\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e0.85 \u0026ndash; 4.70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e0.169\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 198px;\"\u003e\n \u003cp\u003e\u0026gt;24 Hours\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e2.19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e1.01 \u0026ndash; 4.74\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e0.072\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 264px;\"\u003e\n \u003cp\u003eAge (years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e0.92\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e0.81 \u0026ndash; 1.04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.076\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 264px;\"\u003e\n \u003cp\u003eHours since onset of pain\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e1.58\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e1.14- 2.20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 264px;\"\u003e\n \u003cp\u003eLeukocytes (x10\u0026sup3;/\u0026mu;L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e1.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e0.99 - 1.12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.077\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 264px;\"\u003e\n \u003cp\u003eBands (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e1.22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e1.09 \u0026ndash; 1.36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 264px;\"\u003e\n \u003cp\u003eSodium (mEq/L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e0.75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e0.60 \u0026ndash; 0.92\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.039\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 264px;\"\u003e\n \u003cp\u003eAppendicular diameter (mm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e1.18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e0.98 \u0026ndash; 1.42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e0.173\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\" style=\"width: 586px;\"\u003e\n \u003cp\u003e\u003cem\u003eAnalysis using binary logistic regression. Crude odds ratios (ORs), 95% confidence intervals (CIs), and p values are reported.\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" valign=\"top\" style=\"width: 589px;\"\u003e\n \u003cp\u003eTable 4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" valign=\"top\" style=\"width: 589px;\"\u003e\n \u003cp\u003eMultivariate logistic regression model for predictors of complicated appendicitis\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 201px;\"\u003e\u003cbr\u003eAge (years)\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003e0.92\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003e0.81 \u0026ndash; 1.04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e0.18\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 201px;\"\u003e\n \u003cp\u003eLeukocytes (x10\u0026sup3;/\u0026mu;L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003e1.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003e0.99 \u0026ndash; 1.12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e0.09\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 201px;\"\u003e\n \u003cp\u003eBands (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003e1.22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003e1.09 \u0026ndash; 1.36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 201px;\"\u003e\n \u003cp\u003eSodium (mEq/L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003e0.75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003e0.60 \u0026ndash; 0.92\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e0.004\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 201px;\"\u003e\n \u003cp\u003eAppendicular diameter (mm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003e1.18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003e0.98 \u0026ndash; 1.42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e0.08\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 201px;\"\u003e\n \u003cp\u003eFever (present)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003e5.58\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003e1.89 \u0026ndash; 16.42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e0.002\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 201px;\"\u003e\n \u003cp\u003eAppendicolith (present)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003e1.42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003e1.10 \u0026ndash; 1.83\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e0.006\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" valign=\"top\" style=\"width: 589px;\"\u003e\n \u003cp\u003e\u003cem\u003eModel fitted with enter method, Nagelkerke R\u0026sup2;: 0.043, Hosmer\u0026ndash;Lemeshow goodness-of-fit test: \u0026chi;\u0026sup2; = 4.11 p = 0.767\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Acute appendicitis, complicated appendicitis, pediatrics, risk factors, multivariate analysis","lastPublishedDoi":"10.21203/rs.3.rs-7187653/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7187653/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eObjective\u003c/h2\u003e\u003cp\u003eTo identify clinical, laboratory, and imaging factors associated with complicated appendicitis in a Mexican pediatric population using multivariate analysis.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eThis retrospective, observational, analytical, cross-sectional study was conducted at a tertiary care hospital in Mexico City. A total of 134 patients under 18 years of age with a histopathological diagnosis of acute appendicitis were included from January 2019 and March 2024. Cases presenting with gangrene, perforation, or abscess were classified as complicated appendicitis. Clinical, laboratory, and imaging variables were analyzed using bivariate and multivariate logistic regression.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eComplicated appendicitis was present in 28.3% of patients. In multivariate analysis, fever at admission (OR 5.58, 95% CI: 1.89\u0026ndash;16.42, p\u0026thinsp;=\u0026thinsp;0.002), band cell percentage (OR 1.22, 95% CI: 1.09\u0026ndash;1.36, p\u0026thinsp;=\u0026thinsp;0.001), hyponatremia (OR 0.75, 95% CI: 0.60\u0026ndash;0.92, p\u0026thinsp;=\u0026thinsp;0.004), and presence of an appendicolith (OR 1.42, 95% CI: 1.10\u0026ndash;1.83, p\u0026thinsp;=\u0026thinsp;0.006) were significantly associated with complicated cases.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eSimple and readily available variables at hospital admission\u0026mdash;such as fever, serum sodium levels, bandemia, and the presence of an appendicolith\u0026mdash;can aid in stratifying the risk of complicated appendicitis in children, facilitating more timely and targeted diagnostic and therapeutic decisions.\u003c/p\u003e","manuscriptTitle":"Clinical, Laboratory and Imaging Predictors of Complicated Appendicitis in Children: A Multivariate Analysis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-30 08:12:11","doi":"10.21203/rs.3.rs-7187653/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"0effc9f5-6421-4770-b400-83bf677821ac","owner":[],"postedDate":"July 30th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-08-07T14:08:54+00:00","versionOfRecord":[],"versionCreatedAt":"2025-07-30 08:12:11","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7187653","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7187653","identity":"rs-7187653","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}