Appendicitis – a diagnosis that never gets old especially when it occurs in the young! | Blog

In a recently released issue of




), 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%),…

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