Appendicitis in children less than 3 years of age: a 28-year review

Abstract

Appendicitis is the most common surgical abdominal emergency in the pediatric population, but is rarely considered in children less than 3 years of age. The goal of this study was to identify the presenting symptoms and signs in this age group and examine their subsequent management and outcome. A 28-year experience of a single pediatric surgeon in academic practice was reviewed; 27 children less than 3 years old (mean 23 months) comprised 2.3% of all children with appendicitis in his series. The most common presenting symptoms were vomiting (27), fever (23), pain (21), anorexia (15), and diarrhea (11). The average duration of symptoms was 3 days, with 4 or more days in 9 children. Eighteen children were seen by a physician before the correct diagnosis was made; 14 were initially treated for an upper respiratory tract infection, otitis media, or a urinary tract infection. The most common presenting signs were abdominal tenderness (27), peritonitis (24), temperature 38.0 degrees C or more (21), abdominal distension (18), Leukocytosis (<12.0 x 10(3)/mm(3)) was found in 18, tenderness was localized to the right lower quadrant (RLQ) in 14 and was diffuse in 10. Abdominal radiographs demonstrated findings of a small-bowel obstruction (SBO) in 14 of 21 patients, a fecalith in 2, and a pneumoperitoneum in 1. Contrast enemas were performed in 6 children, 5 of whom had a phlegmon or an abscess. Perforated appendicitis was found in all 27 patients. An appendectomy was performed in 25 and a RLQ drain was placed in 18. Postoperative antibiotics were administered to 17 children for an average of 6 days. Two patients underwent interval appendectomies, 1 following treatment with IV antibiotics and 1 following surgical drainage. The average time to resume oral intake was 7 days and the average hospital stay was 21 (median 15) days. Sixteen patients had 22 complications, which included 6 wound infections, 4 abscesses, 4 wound dehiscences, 3 pneumonias, 2 SBOs, 2 incisional hernias, and 1 enterocutaneous fistula. Perforated appendicitis was found in all children less than 3 years old, resulting in very high morbidity (59% complications), which may be attributed to the 3-5-day delay in diagnosis. Although appendicitis is uncommon in this age group, it should be seriously considered in the differential diagnosis of children under the age of 3 years who present with the triad of abdominal pain, tenderness, and vomiting.

Clinical Significance of Fever and Leukocytosis in Diagnosis of Acute Appendicitis in Children Who Visit Emergency Department With Abdominal Pain

“…We assume this is because we included children of all pediatric ages, from 1 - years, and the fact that the frequency of acute appendicitis is relatively low in children aged ≤ 3 years. Among the 119 acute appendicitis patients, only two were ≤ 3-years-of-age (1.6%), similar to result reported by Alloo et al [6].…”

“…The diagnostic approaches of two scoring systems [10,21] have been verified as being useful in diagnosis [8,9]. However, the diagnostic value of fever or leukocytosis is debatable [3,6,[12][13][14]21]. Monneuse et al analyzed 326 patients suspected of acute appendicitis prior to surgical intervention and reported that fever or leukocytosis was not detected in 15.6% of the patients [14].…”

“…Furthermore, communication difficulties related to the young age of a pediatric patient can make a diagnosis more time-consuming and difficult, compared to adults [3]. A misdiagnosis rate of 28% -57% has been reported in children ≤ 12-years-of-age [3][4][5][6][7].…”

“…Fever and leukocytosis are included in both scoring systems, and several reports have indicated that the presence of fever is indicative of acute appendicitis [6,12,13]. However, in another study, in adults diagnosed with acute appendicitis, 15.6% had no fever or leukocytosis [14].…”

White blood cell count and C-reactive protein together remain useful for diagnosis and staging of acute appendicitis in children

“…[11,12,19] However, children with complicated AA were significantly younger than those with simple AA. In the group of children up to 5 years old, more than 50% cases of AA were complicated, [22][23][24] probably because the diagnosis of complicated AA is a particularly difficult one in this age group. Interestingly, the negative appendicectomy rate in this series was similar in all age groups.…”