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Appendicitis in 4 year old symptoms. Appendicitis in Young Children: Symptoms, Diagnosis, and Challenges for Healthcare Providers

by alexxlab

What are the symptoms of appendicitis in children under 5 years old. How does appendicitis present differently in young children compared to adults. Why is diagnosing appendicitis in young children challenging for general practitioners. What diagnostic tools are most effective for identifying appendicitis in children under 5.

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Understanding Appendicitis in Young Children

Appendicitis, an inflammation of the appendix, is a common surgical emergency in children. However, diagnosing this condition in children under five years old presents unique challenges for healthcare providers. The atypical presentation and difficulty in communication with young patients often lead to delayed diagnosis and increased risk of complications.

Prevalence and Epidemiology

Appendicitis is relatively rare in children under five, but its incidence increases with age. Studies have shown that the rate of appendicitis in this age group has changed over time. For instance, a Danish study observed changes in the epidemiology of acute appendicitis and appendectomy in children between 1996 and 2004. Understanding these trends is crucial for healthcare providers to maintain vigilance in diagnosing this condition in young patients.

Unique Anatomical Considerations in Young Children

The anatomy of the appendix in young children differs from that in adults, contributing to the diagnostic challenge. How does the appendix’s position change as a child grows?

  • In fetuses and young children, the appendix is often more centrally located in the abdomen.
  • As children grow, the appendix gradually moves to its typical position in the right lower quadrant.
  • The variable position can lead to atypical pain localization, making diagnosis more difficult.

Research by Maisel (1960) demonstrated that the position of the human vermiform appendix varies between fetal and adult age groups. This anatomical difference is a crucial factor for healthcare providers to consider when evaluating abdominal pain in young children.

Atypical Symptoms in Children Under Five

Unlike adults, young children with appendicitis often present with non-specific symptoms. What are the most common symptoms of appendicitis in children under five years old?

  • Abdominal pain (often diffuse rather than localized)
  • Vomiting
  • Fever
  • Diarrhea (more common in young children than adults)
  • Irritability or lethargy
  • Loss of appetite

Horwitz et al. (1997) emphasized the importance of diarrhea as a presenting symptom of appendicitis in very young children. This symptom, often associated with gastroenteritis, can lead to misdiagnosis and delayed treatment.

Diagnostic Challenges for General Practitioners

Diagnosing appendicitis in young children poses several challenges for general practitioners. Why is it so difficult to identify this condition in patients under five years old?

  1. Limited communication: Young children may struggle to describe their symptoms accurately.
  2. Atypical presentation: The classic signs of appendicitis are often absent or unclear in this age group.
  3. Overlapping symptoms: Many symptoms mimic other common childhood illnesses.
  4. Difficulty in physical examination: Young children may be uncooperative or unable to localize pain.
  5. Rapid progression: Appendicitis can advance quickly in young children, leading to perforation.

Nance et al. (2000) described appendicitis in young children as a “continuing diagnostic challenge,” highlighting the need for heightened awareness and improved diagnostic strategies among healthcare providers.

Diagnostic Tools and Their Effectiveness

Given the challenges in clinical diagnosis, various diagnostic tools play a crucial role in identifying appendicitis in young children. Which diagnostic methods are most effective for this age group?

Laboratory Tests

Blood tests can provide valuable information, but their accuracy in young children is debated. What are the most useful laboratory markers for appendicitis in children under five?

  • White Blood Cell (WBC) count: Often elevated in appendicitis, but not specific
  • C-reactive protein (CRP): Can be helpful, especially when combined with other markers
  • Neutrophil count and left shift: May indicate inflammation

Wang et al. (2007) studied the use of white blood cell count and left shift in diagnosing appendicitis in children. While these markers can be helpful, they are not definitive and should be considered alongside other clinical findings.

Imaging Studies

Imaging plays a crucial role in diagnosing appendicitis, especially in young children where clinical signs may be unclear. Which imaging modalities are most effective for this age group?

  • Ultrasound: Non-invasive and radiation-free, often the first-line imaging choice
  • Computed Tomography (CT): Highly accurate but involves radiation exposure
  • Magnetic Resonance Imaging (MRI): Emerging as a radiation-free alternative to CT

Saito et al. (2013) investigated the use and accuracy of diagnostic imaging for pediatric appendicitis across different hospital types. Their findings emphasized the importance of appropriate imaging selection based on the clinical scenario and available resources.

Risk Factors and Protective Elements

Understanding the risk factors for appendicitis in young children can aid in early diagnosis and prevention. Are there any known protective factors against appendicitis in this age group?

Potential Risk Factors

  • Family history of appendicitis
  • Certain dietary habits (e.g., low fiber intake)
  • Environmental factors (still under investigation)

Protective Factors

Interestingly, some studies have suggested potential protective factors against appendicitis in young children. Alves et al. (2008) conducted a case-control study investigating whether breastfeeding provides protection against acute appendicitis. While more research is needed, this study highlights the potential role of early nutrition in appendicitis risk.

Treatment Approaches and Outcomes

Once diagnosed, prompt and appropriate treatment is crucial for young children with appendicitis. What are the current treatment approaches, and how do outcomes differ in this age group?

Surgical Intervention

Appendectomy remains the standard treatment for appendicitis in most cases. However, the approach may vary based on the child’s age and the severity of the condition:

  • Open appendectomy: Traditional surgical approach
  • Laparoscopic appendectomy: Minimally invasive technique, often preferred when feasible
  • Interval appendectomy: In cases of perforated appendicitis, initial management with antibiotics followed by delayed surgery

Non-Surgical Management

In recent years, there has been growing interest in non-operative management of uncomplicated appendicitis, even in children. This approach typically involves antibiotic treatment and close monitoring. However, its efficacy and safety in very young children are still under investigation.

Outcomes and Complications

The outcomes of appendicitis treatment in young children can vary significantly based on several factors. What are the most common complications, and how do they differ from those in older children or adults?

  • Perforation: More common in young children due to delayed diagnosis
  • Abscess formation: Can occur as a complication of perforated appendicitis
  • Wound infections: Risk may be higher in cases of perforated appendicitis
  • Intestinal obstruction: A potential long-term complication

Bansal et al. (2012) studied the influence of age on presentation and outcome of appendicitis in children less than 5 years old. Their findings highlighted the importance of early diagnosis and intervention to improve outcomes in this challenging age group.

Future Directions and Research Needs

As our understanding of appendicitis in young children evolves, several areas require further investigation. What are the key research priorities for improving diagnosis and management in this age group?

  1. Development of age-specific diagnostic algorithms
  2. Evaluation of novel biomarkers for early and accurate diagnosis
  3. Assessment of long-term outcomes following different treatment approaches
  4. Investigation of genetic and environmental factors influencing appendicitis risk
  5. Refinement of imaging protocols to minimize radiation exposure while maintaining diagnostic accuracy

Ongoing research in these areas will be crucial for enhancing our ability to diagnose and treat appendicitis effectively in young children, ultimately improving outcomes and reducing complications.

Emerging Diagnostic Technologies

Advancements in medical technology offer promising avenues for improving appendicitis diagnosis in young children. What are some innovative approaches being explored?

  • Point-of-care ultrasound: Enabling rapid bedside assessment
  • Artificial intelligence-assisted imaging interpretation: Enhancing diagnostic accuracy
  • Novel biomarker panels: Combining multiple markers for improved specificity
  • Wearable technology: Monitoring physiological parameters for early detection

These emerging technologies hold the potential to revolutionize the diagnosis of appendicitis in young children, addressing many of the current challenges faced by healthcare providers.

Appendicitis in children less than five years old: A challenge for the general practitioner

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Appendicitis in Children | Cedars-Sinai

ABOUT

CAUSES
DIAGNOSIS

TREATMENT

NEXT STEPS

What is appendicitis in children?

Appendicitis is a painful swelling and infection of the appendix.  It is a medical emergency. The appendix can burst or rupture. This is serious and can lead to more infection. If not treated, it can be fatal.

The appendix is a thin, finger-shaped tube that is joined to the large intestine. It sits in the lower right part of the belly (abdomen). Experts don’t know for sure what role the appendix has in the body. It is not a vital organ. Removing it is not harmful.

Surgery to remove the appendix is called an appendectomy. It is the most common type of emergency surgery for children. Most children recover with no long-term problems.

What causes appendicitis in a child?

Appendicitis happens when the inside of the appendix is blocked by something, causing an infection. The blockage may be caused by nose or mouth fluid, called mucus. It can also occur because of stool or parasites. Or the blockage may be caused by a bend or twist in the appendix itself.

The appendix then becomes sore and inflamed or swollen. This is because the germs (bacteria) in the appendix begin to increase quickly. As the swelling and soreness get worse, the blood supply to the appendix is cut off.

All parts of the body need the right amount of blood flow to stay healthy. When blood flow is reduced, the appendix starts to die. The appendix will burst or rupture as its walls start to get holes. These holes let stool, mucus, and other substances leak through and get inside the belly or abdomen. A serious infection called peritonitis may occur in the belly when the appendix bursts. If not treated, it can be fatal.

Which children are at risk for appendicitis?

Most cases of appendicitis happen between the ages of 10 and 30 years. Children with cystic fibrosis may have a greater risk. Having a family history of appendicitis may also increase a child’s risk for this condition.

What are the symptoms of appendicitis in a child?

Each child’s symptoms may vary. Below are some common symptoms of appendicitis.

Pain in the belly (abdomen) is the most common symptom. This pain:

  • May start in the area around the bellybutton, and move to the lower right-hand side of the belly. Or it may start in the lower right-hand side of the belly.
  • Often gets worse as time passes
  • May be worse when the child is moving, taking deep breaths, being touched, or coughing and sneezing
  • May be felt all over the belly if the appendix bursts

Other common symptoms include:

  • Upset stomach (nausea) and vomiting
  • Loss of appetite
  • Fever and chills
  • Changes in behavior
  • Trouble having a bowel movement (constipation)
  • Loose stool (diarrhea)
  • Swollen belly in younger children

How is appendicitis diagnosed in a child?

Your child’s healthcare provider will take a health history and do a physical exam. The provider may also order tests, including:

  • Abdominal ultrasound. This imaging test uses high-frequency sound waves and a computer to create images of blood vessels, tissues, and organs. It is used to see internal organs as they work.
  • CT scan. This imaging test uses both X-rays and computer technology to show detailed images of any part of the body. This includes the bones, muscles, fat, and organs. It is more detailed than a general X-ray.

Other tests may include:

  • Blood tests. These tests check for infection and inflammation. They can also see if there are any problems with other abdominal organs, such as the liver or pancreas.
  • Urine test. This test can tell if there is a bladder or kidney infection, which may have some of the same symptoms as appendicitis.

Symptoms of appendicitis may look like other health problems. Always see your child’s healthcare provider for a diagnosis.

How is appendicitis treated in a child?

Treatment will depend on your child’s symptoms, age, and general health. Appendicitis is a medical emergency. It is likely the appendix will burst and cause a serious, deadly infection. For this reason, your child’s healthcare provider will likely advise that your child have surgery to remove the appendix. Your child may be given antibiotics and fluids through an IV before surgery starts.

Surgery is the most common treatment for appendicitis. But for some children, the healthcare provider may give antibiotics instead of surgery.

The appendix may be removed in two ways:

  • Open or traditional surgery. Your child is given anesthesia. A cut or incision is made in the lower right-hand side of the belly. The surgeon finds the appendix and removes it. If the appendix has burst, a small tube or shunt may be placed to drain out pus and other fluids from the belly. The shunt will be taken out in a few days, when the surgeon feels the infection is gone.
  • Laparoscopic surgery. Your child is given anesthesia. This method uses a few small incisions and a camera called a laparoscope to look inside the belly. The surgical tools are placed through one or more small incisions. The laparoscope is put in through another incision. This method is not usually done if the appendix has already burst.

Interval appendectomy

Sometimes the appendix bursts, and a collection of infected fluid or pus (abscess) may form. If this happens and your child is stable, the provider may recommend not removing the appendix right away. Instead, the provider may want to treat the infection first and drain the infected fluid from the abscess. The appendix will be removed later. This delayed surgery is called an interval appendectomy.

For an interval appendectomy, your child may first have IV antibiotics. These are given through an IV tube called a PICC line, or a peripherally inserted central catheter. This is done for about 10 to 14 days. In addition, the provider may use CT or ultrasound-guided images to drain the abscess. Once the infection and inflammation are gone, your child will have surgery to remove the appendix about 6 to 8 weeks later.

After surgery

A child whose appendix ruptured will have to stay in the hospital longer than a child whose appendix was removed before it burst. Some children will need to take antibiotics by mouth for a certain period of time after they go home.

After surgery, your child will not be allowed to eat or drink anything for a certain period of time. This lets the intestine heal. During this time, fluids will be given by IV into the bloodstream. Your child will also have antibiotics and medicines to ease pain through the IV.

At some point, your child will be able to drink clear liquids such as water, sports drinks, or apple juice. He or she will slowly move on to solid foods.

After your child leaves the hospital, the healthcare provider will likely limit his or her activities. Your child should not do any heavy lifting or play contact sports for a few weeks after surgery. If a drain is still in place when your child goes home, he or she should not take a bath or go swimming until the drain is removed.

You will be given a prescription for pain medicine for your child to take at home. Some pain medicines can make a child constipated, so ask your healthcare provider or pharmacist about any side effects. Moving around after surgery rather than lying in bed can help prevent constipation. Drinking fruit juices may also help. Once your child can have solid foods again, eating fruits, whole grain cereals and breads, and vegetables can also help stop constipation.

Most children who have their appendix removed will have no long-term problems.

What are the complications of appendicitis in a child?

An irritated appendix can quickly turn into an infected and ruptured appendix. This can happen in a few hours. A ruptured appendix is an emergency situation. If not treated, it could be fatal. When the appendix ruptures, germs (bacteria) infect the organs inside the abdominal cavity. This causes a bacterial infection called peritonitis. The bacterial infection can spread very quickly. It may be hard to treat if diagnosis is delayed.

When should I call my child’s healthcare provider?

An infected appendix can burst or rupture. This is an emergency situation and could be fatal. If you think your child has appendicitis, call your child’s provider or go to the emergency room right away.

Key points about appendicitis in children

  • Appendicitis is a painful swelling and infection of the appendix. It is a medical emergency.
  • The appendix can burst or rupture, causing more infection. If not treated, it can be fatal.
  • Healthcare providers will likely recommend that the child’s appendix be removed.
  • An appendectomy is the most common type of emergency surgery for children.
  • Most children recover with no long-term problems.

Next steps

Tips to help you get the most from a visit to your child’s healthcare provider:

  • Know the reason for the visit and what you want to happen.
  • Before your visit, write down questions you want answered.
  • At the visit, write down the name of a new diagnosis, and any new medicines, treatments, or tests. Also write down any new instructions your provider gives you for your child.
  • Know why a new medicine or treatment is prescribed and how it will help your child. Also know what the side effects are.
  • Ask if your child’s condition can be treated in other ways.
  • Know why a test or procedure is recommended and what the results could mean.
  • Know what to expect if your child does not take the medicine or have the test or procedure.
  • If your child has a follow-up appointment, write down the date, time, and purpose for that visit.
  • Know how you can contact your child’s provider after office hours. This is important if your child becomes ill and you have questions or need advice.

which side is it, causes, symptoms, signs, diagnosis, treatment (removal operation), complications in children, women, men

Causes

Classification

Symptoms

Diagnosis

Treatment

Complications 90 003

Forecast

Appendicitis is an inflammation of the appendix, which is a vermiform appendix of the caecum. It has a length of 4 to 10 cm and a diameter of 5 to 7 mm. The appendix is ​​usually located on the lower right side of the abdomen. Its structure is similar to the structure of the rest of the intestine: it also has a wall of 4 layers and is as thick as any other intestine.

The appendix is ​​not involved in digestion and has long been considered a useless organ. But it was found that its prophylactic removal at an early age leads to the development of chronic intestinal diseases and various infections. There is a lot of lymphoid tissue in the process itself, so it is now believed that it is part of the immune system, and its removal is performed only with inflammation that poses a threat to life.

Acute appendicitis is one of the most common diseases in surgery, but it is not so easy to diagnose. The problem is that the symptoms in each case may be slightly different, and it is necessary to differentiate this pathology from many others that have similar manifestations.

Appendicitis is most common in children between the ages of 6 and 12 and in adults between the ages of 18 and 42, and is twice as common in women as in men. The overall incidence is up to 6 people per 1000 people, which makes this pathology the most common in surgery after pancreatitis and cholecystitis.

Causes and triggers

Despite the widespread prevalence of the disease, the exact causes of appendicitis have not yet been established. The fact is that inflammation of the process can be caused by various reasons, and in each case they are individual. It is usually caused by blockage of the lumen of the appendix and the inflammatory process that has begun in it.

The root cause most often becomes the impossibility of evacuating any food that gets into it from the process, since the peristalsis in it is insufficient, and it is a narrow blind pocket. Therefore, any undigested food, as well as any heavy swallowed objects, such as dental fillings, can get into it. According to statistics, frequent meat consumption also increases the incidence of appendicitis among the population.

Putrefactive processes quickly begin in the appendix, which causes inflammation – acute appendicitis. The process begins with the mucosa and spreads to deeper layers, but if the cause is thrombosis of one of the vessels in the appendix, then gangrene develops, which comes from the deeper layers and quickly covers the entire organ.

The causative agents of the inflammatory process are usually anaerobic bacteria that do not require oxygen for their vital activity. They penetrate the appendix from the outside along with food and cause an attack of appendicitis in 90% of cases. In people with weak immunity, another route of infection is possible – by transferring bacteria through the blood or lymph, but such cases are relatively rare.

Also, pathology can develop when the process is blocked by helminths, feces, or with intestinal edema, if another inflammatory intestinal disease has developed.

Classification

Appendicitis is of different forms:

  • catarrhal or simple, it affects only the mucosa of the process;
  • phlegmonous – affects all layers, both superficial and deeper;
  • gangrenous – with the development of gangrene, that is, tissue necrosis in all layers;
  • perforative – with the formation of a hole in the wall of the process;
  • empyema is a kind of phlegmonous form, but differs in that a cavity with pus appears in the clogged process.

This classification system is widely used in Russia.

Symptoms

The main symptom of appendicitis is pain, often occurring at night or in the morning. First, it is felt in the epigastric region – on the left under the ribs, where the stomach is located. Sometimes it has a diffuse character, when the patient cannot say exactly where it hurts, since such pain with appendicitis is weak and its location is difficult to establish.

The first painful sensations are usually mild, intermittent, and may subside at times, and then reappear. The pain may be spasmodic.

However, after 2-3 hours the pain becomes definite, strong and constant – it shifts to the right area of ​​the abdomen, below the navel. This phenomenon is called Kocher’s symptom, and this is one of the important signs of appendicitis.

In addition, other manifestations are possible in various combinations and severity:

  1. Nausea, vomiting occurs in 70% of cases, due to irritation of the nerve endings in the peritoneum. Vomiting is usually single or double.
  2. An increase in temperature – for the first 12 hours, it usually stays up to 37.5 ° C, rarely higher. Then it rises to 38 ° C and above, with the appearance of concomitant symptoms: chills, sweating, weakness.
  3. Loose stools usually occur when the appendix is ​​close to the rectum and its nerve endings are irritated.
  4. Frequent urination also occurs when the nerve endings of the bladder and ureter are irritated with the close location of the appendix. It happens more often in women.
  5. General weakness is a consequence of intoxication of the body.

Each of these symptoms is general in nature and in itself does not make it possible to make a diagnosis. However, their combination makes it possible to suspect inflammation of the appendix with a high probability.

Symptoms are the same for both women and men at any age, but they are more pronounced in children, which allows for a faster diagnosis.

The listed symptoms are classic, they appear in the typical position of the process, which is not always found in practice.

The appendix is ​​not always located strictly in the right lower part of the abdominal cavity. In some people, it happens in other places – these are the individual characteristics of the body and the structure of the intestine.

Up to 8% of cases occurs with an atypical location, which has its own classification:

  • retrocecal – behind the intestine;
  • subhepatic – under the liver;
  • pelvic – in the small pelvis;
  • left side – left side.

Accordingly, pain also appears in various places – in the right hypochondrium, on the left side of the abdomen, and even in the thigh, depending on which side appendicitis develops. Therefore, such pain can be misleading, and atypical forms of appendicitis are difficult to diagnose based on its location alone, and additional studies are required.

Diagnostics

Since it is almost impossible to check appendicitis on your own due to the ambiguity of symptoms, at the slightest suspicion of this disease, the patient should be examined by a surgeon.

The doctor conducts a survey, assesses the existing manifestations, including Kocher’s symptom, as well as other diagnostic symptoms typical for this pathology – Rovsing, Sitkovsky, Voskresensky, Obraztsov, Cope. They are based on the appearance or increase of pain in a certain position of the patient or with a certain movement.

A blood test is also performed, where the doctor is especially interested in the level of leukocytes: already on the first day of illness, it rises to 11-15 thousand / μl, then even more. Immature leukocytes appear in the blood, the number of eosinophils increases.

Of the instrumental methods in the diagnosis of appendicitis, ultrasound is used, but this method does not give guarantees, but it allows you to exclude many other diseases with similar manifestations. Ultrasound can confirm or rule out appendicitis by 90%.

The CT method is more reliable, its informative value is 95%.

When diagnosing, inflammation of the appendix is ​​differentiated from other pathologies of the abdominal cavity: renal colic, pyelonephritis, cholecystitis, pancreatitis, gastroenteritis and some others. Sometimes additional consultations of other specialized specialists and additional studies are required to exclude similar pathologies.

Treatment

Usually the treatment of appendicitis is performed by one method – removal. The operation is performed in different ways, but laparoscopy of appendicitis is preferable, as a more gentle method.

But much is determined by the severity of the patient’s condition, the timing in which he got to the hospital, and the developed complications. So, on the 3-4th day of inflammation, if purulent peritonitis has already occurred, the operation is performed only with an incision, since complete disinfection of the abdominal cavity is required, which cannot be done by the laparoscopic method.

With the development of appendicular infiltrate, the operation is postponed, and antibiotic therapy is prescribed. Drainage of the infiltrate is also performed to remove purulent contents from it. Drainage in some cases is installed for several months. In the case of an appendicular abscess, antibiotic treatment is also carried out first, and the removal of the appendix is ​​performed later – after 1-3 months.

In case of catarrhal appendicitis, the appendix is ​​removed, and a course of antibiotics is not required, and in case of phlegmonous or gangrenous appendicitis, they are always prescribed, immediately after the operation. Also, during the operation, material is taken from the appendix and seeding is performed to study the microflora and its sensitivity to antibiotics – for further correction of treatment.

After the removal of the appendix for the recovery period, a restriction of heavy physical activity for 2-3 months is prescribed. The diet after appendicitis is sparing: food should not irritate the intestines until healing occurs.

Complications

Inflammation of the appendix is ​​primarily dangerous for its consequences. Already after 2 days, complications may develop:

  • peritonitis – inflammation of the peritoneum, which quickly acquires a purulent character and leads to death;
  • appendicular abscess – the formation of a limited abscess inside the peritoneum when the process is ruptured;
  • abscesses of the abdominal cavity – individual abscesses;
  • phlegmon – extensive inflammation of the tissues of the abdominal wall with the formation of pus;
  • pylephlebitis – septic thrombophlebitis of the veins;
  • sepsis is a general infection of the blood.

All these complications are extremely life-threatening and require immediate treatment.

Forecast

In the absence of complications and a quick visit to the hospital, the prognosis is good – the patient spends only a few days in the hospital and quickly returns to his usual life.

With the development of peritonitis and other dangerous complications, the prognosis depends on their severity and the volume of surgical intervention. Therefore, at the first suspicion of appendicitis, you should go to the hospital or call an ambulance.

The author of the article:

Yuliy Sergeevich Gromov

Chief physician of “Polyclinika.ru” on Sukharevskaya, surgeon

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m. Sukharevskaya

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MARINA

15.02.2022 00:15:55 00:15:55

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m. Sukharevskaya

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Gromov Yuli Sergeevich

Dear Julius Sergeevich! I want to thank you from the bottom of my heart for the very competent, professional selection of medical personnel. I have been a patient at the clinic since January 2019. Very often I wrote words of gratitude to doctors who really sincerely love their work. Very attentive, good-natured attitude towards the elderly, sick people. I have 35 years of experience in public education, I also sincerely loved my work, all my students without exception! You are truly a leader WITH A CAPITAL LET!! (WHAT THE HEAD OF THE FISH, THERE WILL BE FINS (regulating movement)! 1. Gritsanchuk A. M. Cardiologist 2. Gavlia G. T. general practitioner 3. Shklyar A.A. gynecologist 4. Markelov G. V. Neurologist 5. Demina E. S. Neurologist 6. Bezverbnaya I.S. Physiotherapist 7. O.B. Kostrodymova Physiotherapist 8. Savilov I.P. urologist 9. Murashko A. A. Ultrasound doctor 10. Kukushkin V. N. Ultrasound doctor 11. Akhmedova E. F. Gastroenterologist. Endoscopist. Pleasantly pleased with the well-coordinated work of the staff, young professionals at the reception. The duty administrators, all young people without exception, very competently, at the highest professional level, make appointments with specialists by the day, by the hour, as per the schedule, as it suits me. And this is yours, as the head of the clinic, the result of such professional work young administrators. I also want to note the excellent work of the nurses in the treatment room (especially the nurse Zalina, unfortunately I don’t know her last name). Julius Sergeevich, you were able to pick up a very strong, professional team of kind, responsive professionals in their field!! I wish prosperity to my beloved clinic. To the entire staff of the clinic, good, good health, well-being and good luck in everything. With great respect! Your patient Rumyantseva Marina Dmitrievna. February 15, 2022

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