Influence of age on clinical presentation, diagnosis delay and outcome in pre-school children with acute appendicitis

Abstract

Background: Unusual clinical presentation of acute appendicitis in preschool children leads to misdiagnosis and complications. We aimed to analyze the influence of age on clinical presentation, laboratory findings and complications in preschool children with acute appendicitis. Methods: From January 2012 until December 2017, 29 children younger than 6 years of age (median 50 months) with acute appendicitis were enrolled in this retrospective study. Patients were grouped according to their age: group 1: < 48 months (n = 13); group 2: > 48 months (n = 16), their clinical data, laboratory results and complications were compared. Results: In group 1, duration of nausea and vomiting was longer, alteration of general state was more frequent and pain in the right fossa iliaca less frequent than in group 2 (p = 0.026, p = 0.000 and p = 0.029, respectively). Heart rate was higher in group 1 than in group 2 (p = 0.012). Leucocyte and polynuclear neutrophil counts were lower in group 1 than in group 2 (p = 0.028 and = 0.004, respectively) but C-reactive protein levels were not different between groups. In the whole cohort however, C-reactive protein at admission value correlated negatively with age (p = 0.025). Abdominal ultrasound allowed diagnosis in 19/29 patients (65.5%), without any difference between groups. Appendicular perforation was more frequent in group 1 than in group 2 (p = 0.003). Perforation was also related to longer hospital stay (p = 0.018). Peritonitis occurred in 21/29 (72%), post-operative ileus in 5/29 (17%) and sepsis in 4/29 (14%) patients without any difference between groups. In the whole cohort, hospital stay correlated negatively with age (p = 0.000). There was no mortality. Conclusions: Among preschool children, those younger than 48 months present with longer duration of preadmission symptoms indicating longer infection course than in older children. Altered general state and higher degree of tachycardia in the younger reflect higher systemic repercussions of the illness. Less specific abdominal pain and dissociation of the inflammatory markers with lower leucocyte-and neutrophil counts and higher Creactive protein levels in the younger may contribute to further diagnosis delay and higher rate of perforation in these patients.

Incidence of Complicated Appendicitis during the COVID-19 Pandemic versus the Pre-Pandemic Period: A Systematic Review and Meta-Analysis of 2782 Pediatric Appendectomies

“…Acute appendicitis is the most common condition in the pediatric population that leads to emergency abdominal surgery [1,2]. Although advanced diagnostic imaging is widely available, the initial diagnosis of appendicitis in children can be challenging, with rates of misdiagnosis reaching 100% in children aged two years or younger [3][4][5][6]. This has been attributed to nonspecific presentation and overlap of symptoms with other common Diagnostics 2022, 12, 127 2 of 13 childhood conditions such as mesenteric lymphadenitis, gastroenteritis, or Meckel's diverticulitis.…”

Validity of Appendicitis Inflammatory Response Score in Distinguishing Perforated from Non-Perforated Appendicitis in Children

“…It is well known that acute appendicitis is one of the most common causes of right lower abdominal pain in pediatric patients, but not every pain in that area is caused by acute appendicitis [ 1 ]. Numerous conditions can simulate the clinical presentation of acute appendicitis, like acute gastroenteritis, mesenteric lymphadenitis, torsion of intra-abdominal organs, Meckel’s diverticulitis, Crohn’s disease, enterobiasis, etc [ 1 , 2 , 3 ]. Typical clinical appearance of acute appendicitis is present only in 30–40% of pediatric patients [ 4 , 5 ].…”

“…On the other hand, due to the appendix’s variable position in the abdominal cavity, the clinical presentation may also significantly vary [ 4 ]. The clinical appearance of acute appendicitis in very young children is not infrequently variable, and misdiagnosis in that age group of pediatric patients is very frequent, leading to an increased rate of complications such as perforation, perityphlitis abscess, diffuse peritonitis or sepsis [ 1 , 5 ]. Despite advances in medicine, acute appendicitis is still a diagnostic problem and a challenge for even experienced emergency physicians and pediatric surgeons.…”

Does age affect the test performance of secondary sonographic findings for pediatric appendicitis?

“…The age groups (<6 years, 6 to <11 years and 11 to <19 years) were determined a priori to attempt to primarily divide into common developmental categories (i.e. young child, school-age, adolescence), which have been previously described in the literature given age-dependent clinical presentations of appendicitis [18,19], and secondarily to maximize statistical power with relatively similar sample sizes between groups.…”