In a recently released issue of Pediatrics (10.1542/peds.2016-0742), Dr. Michelle Stevenson and colleagues looked at the important clinical question of whether time delay from Emergency Department (ED) evaluation to surgery increases the risk of appendiceal perforation in children ages 3-18 years with appendicitis. Previous publications examining this question have been either retrospective, single center, limited by small sample size or survey (opinion) based. This current study overcomes these limitations, since it is a prospective study that enrolled 955 children with appendicitis at 10 centers. Of these children, 247 (25.9%) had perforation diagnosed at surgery by surgical pathology reports, which reminds all of us how common this complication is.
As another quick reminder, I looked up rates of perforation among very young children with appendicitis, since this study excludes those under age 3 years. In a study now 20 years old, Horwitz and colleagues report on 63 children under age 3 years who underwent appendectomy for appendicitis: in their case series, perforation or gangrene was found in 84%.1 They emphasized the challenge of making the diagnosis of appendicitis in young children due to confusing and occult symptomatology, which can delay diagnosis, and thus increase the risk for perforation. In their cohort, 33% presented with diarrhea, and 57% initially received an incorrect diagnosis.
In a more recent review of appendicitis in children under age 5 years, the authors summarize, “Delay in the diagnosis and management predominantly result from poor communication skill [of the young patient], failure to elicit physical signs in irritable children, atypical presentation, and overlap of symptoms with other disorders.”2 Presenting symptoms of appendicitis in the 30 day to 3 year old age group include vomiting (85-90%), pain (35-81%), fever (40-60%), diarrhea (18-46%), irritability (35-40%), grunting respirations (8-23%), lethargy (40%) and right hip mobility limitation with pain and limping (3-23%). Less than one half of children under age 3 years have right lower quadrant abdominal pain, and as we all recognize, the symptoms described could appropriately lead to multiple other diagnostic considerations. Appendicitis is much less common among children under age 4 years (rate of 0.11 per 1,000) than over age 4 years (0.68/1000 for ages 5-9 years and 0.19/1000 for ages 10-14 years), which makes it easier to mistakenly omit from the differential in the youngest age group.3 Diagnostic delay is traditionally blamed for the high rate of perforation (82-92%) in children under age 3 years, but (my added thoughts) perhaps there are also unexplored pathophysiologic factors related to gut or gut wall maturity that contribute.
Stevenson and colleagues’ conclusion about delay of surgery at the academic medical centers in this report is reassuring, and their careful approach to untangling relevant and potentially confounding factors is very interesting. Ultimately 10 predictors were entered in their multivariable regression analysis, and to pique your curiosity, these included age and degree of abdominal tenderness, as well as other descriptors. A subgroup analysis comparing the rate of perforation between those who did (the majority) and did not have CT or ultrasound imaging (255 children or 26% of the sample) revealed that performance of these imaging tests was not significantly associated with increased odds of perforation. This article is a treasure trove of fascinating clinical information at the cutting edge!! Enjoy.
- Horwitz JR, Gursoy M, Jaksic T, Lally KP. Importance of diarrhea as a presenting symptom of appendicitis in very young children. Am J Surg. 1997;173(2):80.
- Almaramhy HH. Acute appendicitis in young children less than 5 years: review article. Italian Journal of Pediatrics. 2017;43:15. doi:10.1186/s13052-017-0335-2.
- Williams NM, Jackson D, Everson NW, Johnstone JM. Is the incidence of acute appendicitis really falling? Annals of The Royal College of Surgeons of England. 1998;80(2):122-124.