Original Contribution
Effect of delay in presentation on rate of perforation in children with appendicitis

https://doi.org/10.1016/j.ajem.2010.04.005Get rights and content

Abstract

Introduction

Appendicitis is the most common emergency operation in children. The rate of perforation may be related to duration from symptom onset to treatment. A recent adult study suggests that the perforation risk is minimal in the first 36 hours and remains at 5% thereafter. We studied a pediatric population to assess symptom duration as a risk factor for perforation.

Methods

We prospectively studied all children older than 3 years who underwent an appendectomy over a 22-month period.

Results

Of 202 patients undergoing appendectomies, 197 had appendicitis. Median age was significantly lower in the perforated group, but temperature and leukocytosis were not. As expected, length of hospital stay was longer in the perforated group (4-13 vs 2-6 days). The incidence of perforation was 10% if symptoms were present for less than 18 hours. This incidence rose in a linear fashion to 44% by 36 hours. Prehospital delays were greater in patients with perforated appendicitis. However, in-hospital delay (from presentation to surgery) was less than 5 hours in the perforated group and 9 hours in the nonperforated group.

Discussion

Appendiceal perforation in children is more common than in adults and correlates directly with duration of symptoms before surgery. Perforation is more common in younger children. Unlike in adults, the risk of perforation within 24 hours of onset is substantial (7.7%), and it increases in a linear fashion with duration of symptoms. In our experience, however, perforation correlates more with prehospital delay than with in-hospital delay.

Introduction

Appendicitis is the most common emergency that requires surgical intervention in children. In the United States, more than 341 000 open or laparoscopic appendectomies are performed each year [1]. Children tend to have higher rates of appendiceal perforation than do adults [2], [3], [4]. Several factors may contribute to this observation. First, children may present with a variety of atypical symptoms, in contrast with the classic periumbilical pain that later migrates to the right lower quadrant. In addition, very young children may have little omentum and intraabdominal fat, allowing peritoneal spread to occur more readily [5], [6]. Finally, children tend to present later than adults, thereby causing a delay in diagnosis that contributes to a higher perforation rate [6].

In 2006, Bickell et al [7] studied the effect of the duration of symptoms on the risk of rupture in 219 adult patients. The study suggested that the risk of rupture rises to 5% after the first 36 hours and remains unchanged thereafter. Although the rate of appendiceal perforation tends to be higher in children, no pediatric-specific study has looked at the risk of rupture over time. We undertook this study to determine the relationship between the rate of perforation and the duration of symptoms in children with appendicitis.

Section snippets

Methods

We prospectively studied all children between the ages of 3 and 18 years who underwent open or laparoscopic appendectomy for suspected appendicitis from October 2006 through August 2008. All patients presented to a tertiary care children's hospital and level I trauma center. Data collected included age, sex, symptoms (abdominal pain, nausea, vomiting, diarrhea, or anorexia), heart rate, temperature, white blood cell count, and, if applicable, findings on imaging studies (ultrasound or computed

Results

A total of 202 consecutive patients aged 3 to 18 years who underwent an appendectomy from October 2006 through August 2008 were studied. Six patients were found at surgery or on pathology to have a normal appendix. These patients were excluded, leaving 197 patients for analysis. Table 1 summarizes patient demographic characteristics, symptoms, and clinical findings. There was no statistical difference in male-female ratio; however, children with perforated appendicitis were significantly

Discussion

Appendectomy is the most common emergency operation performed in children in the United States. Some have suggested that the perforation rate and morbidity in children with appendicitis are similar to those in adults [4], whereas others have reported far higher perforation rates in the pediatric age group [9], [10]. Two main factors can influence the rate of perforation in appendicitis. Very young age is typically associated with a higher rate of rupture [11], reaching 75% in children younger

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