A New Palpation Sign for the Diagnosis of Atypical Forms of Acute Appendicitis (Children and Women of Childbearing Age)

Background Even today, the diagnosis of acute appendicitis (AA) is still problematic. Here, we offer a new palpation sign for the diagnosis of AA. In this study, we evaluate the efficacy of the sign for the diagnosis of atypical forms of AA (i.e., in children and women of childbearing age). following results. In children (aged 0-12, male/female) and in women of childbearing age (aged 12-45), we observed 14 (3,46%) false negative clinical findings for the palpation sign. In children and women of childbearing age, we observed a higher percentage of palpation sign positivity compared to false positivity. The new palpation sign minimizes unindicated revisions of the abdominal cavity, serves as a reliable indicator for surgery and is suitable for the diagnosis of AA in atypical forms (i.e., in children and women of childbearing age) with a sensitivity of 95,57%, a specificity of 95,78%, a positive predictive value of 67,86%, a negative predictive value of 99,50%, a positive likelihood ratio of 24,28, a negative likelihood ratio of 0,05 and an accuracy of 95,9%. The negative appendectomy rate in women of childbearing age was 9.22% and in children 6,72%. We conclude that the new palpation sign is effective (r > 0.95) for the diagnosis of atypical forms of AA (i.e., in children and women of childbearing age). It is aimed principally at the medical practitioners in different parts of the world and in a state of emergency (Covid-19 pandemic, wars, etc.) where the diagnostic facilities and technological resources are limited.


Background
Acute appendicitis (AA) is defined as a non-specific bacterial inflammation of the worm-like appendage of the colon. The doyen of Czechoslovakian surgery, academician Arnold Jirásek, defines acute appendicitis as -an insidious, unpredictable, and dangerous disease which causes diagnostic difficulties with its unpredictable onset and course‖ [1]. In the classic form of AA with typical symptoms, diagnosis is relatively simple, while atypical forms of AA result in diagnostic difficulties [2][3][4][5]. Patients with the most common atypical form of AA include children and women of childbearing age. The course of AA in a woman of childbearing age can be confusing, causing the diagnostic difficulties. This results from an atypical course of pain, where the original Volkovich-Kocher sign is suppressed and a colic pain in the ab-domen or right adnexa is dominant. The anatomical proximity of the appendix to the internal genitalia causes frequent confusion of AA with gynaecological diseases (e.g., an ectopic pregnancy, pelvic inflammatory disease, or complicated ovarian cyst) [6][7][8]. AA is more common in men than in women (3:2) [9]. Despite these statistical data, the lifetime risk of an acute appendectomy in women is higher than in men (2:1), which can be explained by the more demanding diagnostic procedures required for female AA, with a higher number of preventive, negative appendectomies [10]. Delayed AA diagnosis in women of childbearing age may lead to perforation of the appendix, resulting in tragic con-sequences regarding sterility [11][12][13].
Overall, 1-8% of children presenting with abdominal pain have AA [14]. AA is rare condition in children under 6 years of age and is often diagnosed with delay in this age group [15]. Even with the development and availability of sophisticated imaging techniques, these methods have not eliminated complications in cases of paediatric AA, such as perforation, abscess formation, or diffuse peritonitis. A recent study showed a significant increase of perforation in relation with age as follows: 100% < 1 year; 100% 1-2 years; 83,3% 2-3 years; 71,4% 3-4 years; 78,6% 4-5 years and 47,3% 5 years [16][17][18][19]. The reason for this is the delayed diagnosis of the disease. This delay is caused by its non-specific clinical manifestation, which is often covered up by other non-specific childhood diseases, as well as the child's inability to describe and specify their own health problems [20,21]. The rate of incorrect diagnosis concerning AA ranges from 28% to 57% in 2-to 12-year-old children, and is almost 100% in children under 2 years of age [22]. Anamnesis and clinical examination remain the basic diagnostic approaches, and allow approximately 84% of patients with AA to be diagnosed [23]. The aim of this study is to offer surgeons a new palpation sign as a reliable tool for the diagnosis of atypical forms of AA (i.e., in children and women of childbearing age) and an effective indicator for surgical intervention.

Methods
In this study, with the use of the new palpation sign that has been in practice for 12 years (2006-2018), we retrospectively analysed 2245 patients -children (aged 0-12), men (aged 12-18) and women of childbearing

Exclusion criteria
Patients after appendectomy, patients with a history of inflammatory bowel disease (Crohn's disease or ulcerative colitis), clinical symptoms lasting more than

Statistical Analysis
We performed Pearson correlation analysis to determine the correlation between the distribution of the patients' gender and age, as well as their clinical and histological findings.

Results
The demographic data for patients included the

Discussion
In Overall sensitivity and specificity of US is 65,5-76% and 95% and for CT is 72-99% and 84%, respectively [25,36]. Pain in the right hypogastrium in women of childbearing age still presents a diagnostic problem.
The incidence of incorrect diagnoses is as high as 33% [32]. AA is most often mistaken for pelvic    [33,34].
The diagnosis of AA in children is also problematic. In particular, younger children are not able to adequately assess and describe their health problems. In such cases, children are often bad-tempered and refuse to sleep, eat, or drink. Children typically do not respond to caressing and are not satisfied in their mother's arms. In most cases, the mother suspects that the child only has a stomach ache and is unable to substantiate the problem exactly. In such cases, the recommendation of Professor Tošovský applies: -We must never contradict the mother's opinion due to our pro-fessional knowledge. It is the quickest way to a   CT examination was indicated relatively rarely due to concerns related to the hazards of ionizing radiation.
Finally, the retrospective nature of the study is also a limitation. These limitations may form the basis for subsequent studies.

Conclusions
In