Original ArticleAppendicitis in preschool aged children: Regression analysis of factors associated with perforation 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)
- et al.
Appendicitis in children younger than 3 years of age: an 18-year experience
Kaohsiung J Med Sci
(2006) - et al.
Appendicitis in children less than 5 years old: influence of age on presentation and outcome
Am J Surg
(2012) Appendicitis in pre-school children: a continuing clinical challenge. A retrospective study
Int J Surg
(2008)- et al.
Single daily dosing of ceftriaxone and metronidazole vs standard triple antibiotic regimen for perforated appendicitis in children: a prospective randomized trial
J Pediatr Surg
(2008) - et al.
Appendicitis in children aged 13 years and younger
Am J Surg
(1990) - et al.
Importance of diarrhea as presenting symptom of appendicitis in very young children
Am J Surg
(1997) - et al.
Initial laparoscopic appendectomy vs initial non-operative management and interval appendectomy for perforated appendicitis with abscess: a prospective, randomized trial
J Pediatr Surg
(2010) - et al.
Inflamed appendix: a diagnostic problem in children younger than 3 year of age
Aristotle Univ Med J
(2011) - et al.
Appendicitis in children less than 3 years of age: a 28-year review
Pediatr Surg Int
(2004) - et al.
Appendicitis in the young child: a continuing diagnostic challenge
Pediatr Emerg Care
(2000)
Ultrasound for differentiation between perforated and nonperforated appendicitis in pediatric patients
AJR
Cited by (38)
Spatial–temporal clusters of pediatric perforated appendicitis in California
2021, Journal of Pediatric SurgeryCitation Excerpt :Appendicitis is the most common gastrointestinal surgical emergency in children and a well documented child health disparity [1–5]. While appendiceal perforation occurs in approximately 30% of school-aged and adolescent children, more than 50% of children less than 5 years old who present with appendicitis are diagnosed with perforation [5,6]. Children with perforated appendicitis typically experience longer hospital stay, more complicated treatment course, and greater resource utilization than children without perforation [7–9].
Intestinal ultrasound in pediatrics
2021, RadiologiaImpact of COVID-19 on the presentation and course of acute appendicitis in paediatrics
2021, Anales de PediatriaA new clinical score to identify children at low risk for appendicitis
2020, American Journal of Emergency MedicineCitation Excerpt :Diagnosis of AA continues to be a challenge, especially in the youngest children, who often present with abdominal pain accompanied by nonspecific signs. Physicians often face a clinical dilemma in deciding the timing of surgical intervention, since delayed diagnosis of appendicitis is associated with increased morbidity, mortality, and health care costs [3,4]. Today, imaging techniques constitute the basis of diagnosis in the majority of cases, especially abdominal ultrasound as it is innocuous to the patient.
ACR Appropriateness Criteria<sup>®</sup> Suspected Appendicitis-Child
2019, Journal of the American College of RadiologyCitation Excerpt :As a result, presentation and diagnosis may be delayed, which may contribute to a higher rate of perforated appendicitis in the youngest children [5]. While perforated appendicitis tends to be more common in children than adults [6], morbidity is similar to or lower in children than in adults. The most common treatment of appendicitis is appendectomy.
Statistical evaluation of diagnostic tests: A primer for pediatric surgeons
2019, Journal of Pediatric SurgeryCitation Excerpt :A flow diagram for the probability of 30-day readmission is a useful way to display the risk for a given patient (Fig. 3). The fundamental concepts of diagnostics tests and ROC analysis are widely applicable to pediatric surgical research [15–18]. The statistical concepts of sensitivity, specificity, positive and negative predictive values, positive and negative likelihood ratios, odds ratios, ROC curves, and AUC are applicable to many types of research studies, including diagnostic testing studies, biomarker studies, and risk factor analyses.