Source:Becker T, Kharbanda A, Bachur R. Atypical clinical features of pediatric appendicitis.
Acad Emerg Med.
–129; doi:10.1197/j.aem.2006.08.009

The classic description of appendicitis includes the onset of periumbilical pain followed by nausea, then migration of pain to the right lower quadrant (RLQ) and finally, vomiting and fever. However, this progression of symptoms is less common in children than adults.1 Absence of classic symptoms leads to a higher rate of appendiceal perforation in children.2,3 Increased morbidity as a result of diagnostic delays in cases of appendicitis is a common cause of malpractice suits.4 To determine the frequency of atypical clinical features among pediatric patients with appendicitis, researchers from Children’s Hospital Boston and Morgan Stanley Children’s Hospital of New York enrolled children between 3 and 21 years of age with suspected appendicitis over a 20-month period. Standardized data collection forms were completed by the fellowship-trained pediatric emergency physician responsible for the care of the patient. These forms were completed independent of surgical evaluation and prior to diagnostic imaging. Patients were excluded if they were pregnant, or had a history of prior abdominal surgery, chronic medical conditions, or a radiologic study within the prior two weeks. Data were collected on 24 demographic, historical, and physical examination variables. Laboratory, pathology, and operative reports were extracted from the patient’s medical record. The presence or absence of appendicitis was determined from pathologic reports (for those who underwent surgery) or by phone call follow-up two weeks after the emergency department visit (for patients who did not undergo surgery). Typical features, defined prior to the start of the study, included anorexia, nausea, pain migration, pain duration of <48 hours, guarding, RLQ tenderness, gradual onset of pain, absence of diarrhea, decreased bowel sounds, percussive tenderness, Rovsing’s sign (palpation of the abdomen in the lower left quadrant results in pain in the RLQ), rebound pain, fever (≥38°C), white blood cell count (WBC) >10,000 per mm3, and an absolute neutrophil count (ANC) >7,500 per mm3. Atypical findings were defined as the absence or opposite of those classic findings.

Of 755 patients enrolled, 270 patients had appendicitis (median age = 12.8 years) compared with 485 patients without appendicitis (median age = 11.6 years). Seventeen percent (47/270) of patients with appendicitis had a perforated appendix. Twelve of the 15 classic signs and symptoms of appendicitis (gradual onset of pain, absence of diarrhea, and fever were the exceptions) were significantly more common among patients with appendicitis. However, typical findings were commonly absent among patients with appendicitis. Patients with appendicitis commonly presented with absence of fever (83%), negative Rovsing’s sign (68%), normal or hyperactive bowel sounds (64%), no rebound pain (52%), absence of pain migration (50%), absence of abdominal guarding (47%), abrupt onset of pain (45%), no anorexia (40%), and maximal tenderness somewhere other than the RLQ (32%). The signs and symptoms of patients with atypical appendicitis were not analyzed separately. Forty-four percent of patients with appendicitis were found to have...

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