Elsevier

Journal of Pediatric Surgery

Volume 50, Issue 9, September 2015, Pages 1569-1573
Journal of Pediatric Surgery

Original Article
Appendicitis in preschool aged children: Regression analysis of factors associated with perforation outcome,☆☆,

https://doi.org/10.1016/j.jpedsurg.2015.02.050Get rights and content

Abstract

Objectives

Apply multivariate regression analysis to determine the significance of clinical variables for perforation outcome of a large series of preschool aged children with appendicitis.

Methods

Retrospective case review of 180 consecutive children < 5 years of age diagnosed with appendicitis during an 8-year period.

Results

This age group accounted for only 9% of all cases of pediatric appendicitis at our institution during the study period. Perforation rate was inversely proportional to patient age, occurring in 100% aged < 1 year, 91% ages 1–2 years, 76% ages 2–3 years, 73% ages 3–4 years, and 57% ages 4–5 years. Risk for perforation increased proportionately with duration of symptoms, ranging from 48% when < 1 day vs 84% when > 1 day; and 93% when > 2 days. One-quarter with perforation had a prior recent medical evaluation with an alternative diagnosis rendered preappendicitis diagnosis. The mean duration of hospitalization was four times longer in those with perforation [8 days] vs no perforation [2 days]. Univariate analysis showed each of the following factors was significantly associated with perforation outcome: younger patient age, female gender, prior medical visit < 48 hours of appendicitis diagnosis, symptom duration, presence of fever, and presence of appendicolith. Multivariate logistic regression combining all significant univariate predictors showed only duration of symptoms and presence of appendicolith were significantly associated with perforation outcome; receiver-operating characteristic curves are generated to evaluate the predictive accuracy of these two factors, both individually and when combined.

Conclusions

Although relatively uncommon in this age group, appendicitis is frequently associated with delayed diagnosis and perforation outcome. Risk for perforation is directly proportional to increasing duration of symptoms. Clinicians must maintain a high index of suspicion for this condition in these younger children, as early diagnosis is essential to maximizing outcome.

Section snippets

Methods

A retrospective case review was conducted of consecutive children aged  5 years with a discharge diagnosis of appendicitis at Maimonides Medical Center, Brooklyn, NY, from 2006 to 2014. Information gathered was: patient age, gender, type and date of onset of symptoms [abdominal pain, vomiting, and fever], date of and diagnosis rendered at any recent prior medical visit, ED-measured body temperature, duration of fever [≥ 38.0 °C] during hospitalization, duration of antibiotic therapy during

Statistical analysis

Normally distributed data are described in terms of mean ± SD while skewed data are presented in terms of median [minimum, maximum]; and categorical data are described in terms of frequency [percent]. To assess interrater agreement in data recording, 35 cases [20% of total] were randomly selected and 9 variables [patient age/gender, fever, WBC count, appendicolith, perforation on pathology report, duration of symptoms [days], days in hospital, perforation on surgery report] were reexamined by 3

Results

Raw demographic data and characteristics percentages for patients distinguished by outcome are summarized in Table 1. Of 40 patients who had a prior medical visit < 48 hours to appendicitis diagnosis, discharge diagnoses at that visit included viral syndrome [20], gastroenteritis [12], acute otitis media [4], UTI [2] and not specified [2].

Fig. 1 gives the breakdown of appendicitis cases at our institution during the 9-year study period. Of the total, 180 [9%] were aged  5 years; of these, 128

Discussion

Appendicitis is a relatively uncommon cause of abdominal pain in younger-aged children, as evidenced by our 9% prevalence rate in preschool aged children relative to all pediatric appendicitis cases. Although always an important diagnostic consideration, alternate diagnoses for abdominal pain occurring with greater frequency in this age group include gastroenteritis, constipation, and intussusception.

Prior studies [4], [5], [12], [14], [16], [19] uniformly show younger-aged children with

Limitations

Of potential deficits with a retrospective analysis, there may have been variance between surgeons in reporting operative findings indicative of perforation; our analysis did not prospectively establish preoperative uniformity in this classification. To limit the possibility of variability in data gathering, we established excellent interrater agreement between reviewers who retrieved data from medical records. Other clinical variables which were not included in the regression model and could

Conclusions

Preschool aged children with appendicitis frequently experience delayed diagnosis and appendiceal perforation. Perforation risk is directly proportional to symptom duration, and is significantly associated with the presence of appendicolith. Clinicians must maintain a high index of suspicion for this relatively uncommon condition in these younger children, as early diagnosis is essential to maximizing outcome. Ultrasound evaluation is relatively insensitive for diagnosing perforated

References (22)

  • E. Blumfield et al.

    Ultrasound for differentiation between perforated and nonperforated appendicitis in pediatric patients

    AJR

    (2013)
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    Funding source: none.

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    Conflict of interest: none.

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