Appendicitis in the young child: a continuing diagnostic challenge.

Abstract

The purpose of this review was to examine the presenting signs and symptoms of children 5 years of age or less who underwent operation for appendicitis. In addition, we sought to determine the rate of perforation of the appendix and the effect on outcome in this age group. Medical records for the period September 1987 to September 1998 were reviewed for all children 5 years of age or less who underwent appendectomy for appendicitis. Data gathered included age at operation, gender, care sought prior to admission for appendectomy, duration of symptoms, signs and symptoms at the time of admission, and length of postoperative hospital stay. Symptoms of diarrhea, emesis, fever, pain, and anorexia were recorded. Physical signs of an abdominal mass, guarding, rebound tenderness, rigidity, and diffuse or focal tenderness were recorded. Diagnostic information included white blood cell count with differential, and radiographic imaging, if obtained. The presence or absence of perforation of the appendix, and abscess formation were based on the intraoperative impression of the operating surgeon. For the 11-year period, 120 patients 5 years of age or less required an operation for appendicitis and had a complete medical database. The mean age was 3.6 +/- 1.3 years; 53% were male. Patients underwent a separate medical evaluation prior to arriving at a definitive diagnosis in 44.2 % cases. The most common presenting symptom was abdominal pain (94%); the most common sign was abdominal tenderness (95.8%). Tenderness was generally diffuse if perforation had occurred (62%) or focal in the nonperforated group (61%). The duration of symptoms in patients with perforation was more than double that of the nonperforated patients (4.7 vs 2.1 days, respectively). The mean white blood cell count (WBC) was 18.3 +/- 7.4 cells/mm3, and did not differ significantly between the perforated and nonperforated groups. A left shift detected in the WBC differential was present in 91%. An abdominal radiograph was obtained in 87%, and demonstrated a fecalith in 18%. A preoperative ultrasound was obtained in 38%, a computed tomographic scan in 7%. At the time of surgery, 74% were found to have evidence of perforation. An abscess was found at the initial surgery in 47% of patients with appendiceal perforation, but in no patient in whom perforation had not occurred. The rate of perforation increased as the age of the patient decreased (100% perforation for age 1 (n = 10) to 69% for age 5, (n = 35). Perforation was associated with a longer hospital length of stay as compared to the nonperforated appendix (median 9 days vs. 3 days, respectively, P < 0.001). There were no deaths in this series. Appendiceal perforation continues to be a common occurrence in the young child and increases in frequency as the age of the patient decreases and the duration of symptoms lengthens. Perforation results in a significant increase in hospital length of stay and rate of abscess formation.