Treatment And Disposition Of Suspected Appendicitis In The Pediatric Patient

Acute Appendicitis In Childhood Pitfalls

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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Acute Appendicitis In Childhood Case Study

Case Study:
A young couple brings in their 18-month-old daughter who has been ill for the past 36 hours. They recount symptoms of fevers as high as 101.9°, vomiting, one episode of diarrhea, and abdominal pain. Other than intermittent bouts of fast breathing and “grunting” noises, she has not had cough or other cold symptoms. An older sibling recently had an upper respiratory infection, with no gastrointestinal symptoms. The child is otherwise in good health with up-to-date immunizations. She currently has a low-grade temperature of 100.4°, with otherwise age-appropriate vital signs. She is not tachypneic. You perform an examination on the tired but alert child and note a slightly distended abdomen and diffuse tenderness with guarding. The chest examination is clear to auscultation. You wonder how to further evaluate this child. Then you grab the order sheet and explain to the parents the tests you are ordering.

Case Study Conclusion:
You order a WBC and an ultrasound to further evaluate this child. She has a leukocytosis of 11,100/μl and the ultrasound reveals an easily visualized appendix, which has inflammation suspicious for appendicitis per the radiologist. You obtain a pediatric surgical consult to confirm. The surgeon agrees that she indeed likely has appendicitis and explains the next step of surgical intervention to the parents. You administer additional pain medications to keep the child comfortable while the child is prepared for her appendectomy.