Risk Management Pitfalls:
1. “The US (which at our institution has a high sensitivity) is negative; therefore, we have adequately ruled out appendicitis.” Again, estimating the pre-test probability is critical in the evaluation of appendicitis in the child. The appendix can be poorly visualized in 30% of studies, the sensitivity is highly variable, and the examination is operator dependent. If the pre-test probability of appendicitis is moderate or high, then a CT scan should be obtained to further evaluate for appendicitis.
2. “Perforated appendicitis in children is most commonly the result of late presentation and will be obvious.” Most cases of perforated appendicitis are due to the delay in diagnosis or misdiagnosis, particularly in young children. Poorly defined symptoms and non-specific findings in a child, along with a good-intentioned parent to treat “stomach aches” can have some impact on delayed presentation; however despite presentation for medical evaluation, 57% to 67% of children under 5 years of age are still misdiagnosed.
3. “This 6-month-old child doesn’t have appendicitis. Children under the age of 2 rarely get appendicitis.” Although it is less common than in children 10 to 17 years of age, children < 3 years of age can account for 1 to 2 cases per 10,000 children per year in the U.S. Infants commonly have atypical symptoms such as cough, grunting, vomiting, and diarrhea. Perforation rates are nearly universal in this age group; therefore, the relative infrequency of appendicitis (with increased morbidity) in this age group should not forego its consideration on the differential diagnosis.
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