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Appendicitis in Children Aged 5 Years and Under

G. Shepherd¹² , S. Jayakumar² , A. Rajimwale² , R. Fisher² , G. Ninan² , S. Nou²

¹Department of Pediatric Surgery, Nottingham Children’s Hospital, Queen’s Medical Centre, Nottingham, UK

²Department of Pediatric Surgery, Leicester Children’s Hospital, Leicester Royal Infirmary, Leicester, UK

 

Correspondence:

Gregory Shepherd

Department of Pediatric Surgery Nottingham Children’s Hospital, Queen’s Medical Centre, Derby Road

Nottingham, UK

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Abstract

Purpose: To examine the presentation, investigation, histological diagnosis and outcome of patients who underwent acute appendicectomy in children aged 5 years and under.

Methods: This is a retrospective case note review of all children aged 5 years and under who underwent emergency appendicectomy at our institution over a two-year period.

Results: Two hundreds and seventy-two patients underwent emergency appendicectomy for a clinical diagnosis of appendicitis. Twenty-three patients were 5 years of age or less (8%) with 11 boys and 12 girls. Three had perforated appendicitis (13%), 13 had non-perforated appendicitis (57%). Six had normal appendicectomies (26%), of which 2 had Meckel’s diverticulitis (9%) and 1 had enterobius vermicularis infestation (4%). Twenty patients had blood sampling for inflammatory markers (87%). Ultrasound was performed in 8 cases (35%). One patient had an intra-abdominal collection post perforated appendicitis (4%) and one patient had an incisional hernia (4%).

Conclusion: Accurate diagnosis of acute appendicitis in this age group remains challenging. Adjuncts to clinical assessment are frequently employed but their accuracy remains poor. The relative low incidence of acute appendicitis in very young children means that it is often overlooked. A high index of suspicion may aid earlier diagnosis and thereby reduce morbidity and length of hospital stay.

Keywords: appendicitis, appendicectomy, young children, pre-school age

 

 

Introduction

The most common condition requiring emergency abdominal surgery in children is acute appendicitis [1]. Appendicitis may present at any age. The characteristic presentation of vague periumbilical abdominal pain followed by vomiting and localization of pain to the right iliac fossa is generally seen in older children [1]. Appendicitis is relatively rare in the very young but is a considerable diagnostic challenge in this age group [2,3,4]. This challenge can result in a delay in diagnosis and treatment and consequently lead to greater morbidity. This may well be a combination of factors including anatomical immaturity with a relative lack of an omental barrier contributing to an accelerated progression to perforation and the resulting sequelae; as well as the communication difficulties that come with the very young [1]. Surprisingly, despite most surgeons and physicians being aware of this difficulty, there is very little literature on the challenges of appendicitis in children under 5 years of age. The aim of this study was to examine the presentation, investigation, histological diagnosis and outcome of patients who underwent acute appendicectomy in children aged 5 years and under.

Material and Methods

A retrospective analysis was carried out for all children aged 5 years and under who underwent emergency appendicectomy for suspected acute appendicitis at Leicester Children’s Hospital, Leicester, UK between January 2007 and December 2008. The histology was reviewed along with the results of any investigations. Incidental or interval appendicectomies were not included in this study. Information gathered included the age, sex, presenting symptoms and signs, duration of abdominal pain prior to presentation; white cell count, neutrophil count, CRP, histology findings, ultrasound findings if performed, time from admission to surgery, open or laparoscopic appendicectomy, duration of postoperative antibiotics, time to discharge and complications.

Results

During the 2 years period, 272 patients underwent emergency appendicectomy for a clinical diagnosis of appendicitis. Of these, 23 patients were 5 years of age or less (8%) (Fig. 1). There were 11 boys and 12 girls. Four children had their appendicectomy performed laparoscopically, 18 were performed open and 1 was converted from laparoscopic to open for a perforated appendicitis with a pelvic mass. Three children had histological evidence of perforated appendicitis (13%), 13 had non-perforated appendicitis (57%), 6 had normal appendicectomies (26%), of which 2 had Meckel’s diverticulitis (9%) and 1 had enterobius vermicularis infestation (4%). Three (13%) patients had histologically normal appendicectomies.

Figure 1. Age of patients undergoing appendicectomy

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Symptoms and signs were similar amongst both those with and without histological signs of appendicitis (Fig. 2). Twenty-two out of 23 (96%) patients had a loss of appetite, 13 of whom had an inflamed appendix, 3 had a perforated appendix, 3 had a normal appendix and 2 had Meckel’s diverticulitis and 1 had enterobius vermicularis. Twenty (87%) patients were tachycardic (as per Advanced Paediatric Life Support (APLS) age range parameters), of which 11 had an inflamed appendix, 3 were perforated, 2 had Meckel’s diverticulitis, 1 had vermicularis and 3 were normal. Sixteen (70%) patients had vomiting, 11 of which had an inflamed appendix, 2 were perforated, 2 had Meckel’s diverticulitis and 1 had vermicularis. Fourteen (61%) patients had pyrexia of 38 or above, of which 7 had an inflamed appendix, 2 were perforated, 2 had Meckel’s diverticulitis and 3 had a normal appendix. Twelve (52%) patients had right iliac fossa (RIF) guarding, of which 6 had an inflamed appendix, 3 were perforated, 1 had Meckel’s diverticulitis, 1 had vermicularis and one was normal. Seven (30%) patients had diarrhea of which 4 had an inflamed appendix, 2 had Meckel’s diverticulitis and 1 had vermicularis. Eight (35%) patients had other non-specific symptoms such as constipation, abdominal distension, sore throat, acute scrotum. Of these 6 had an inflamed appendix, 1 had Meckel’s diverticulitis and 1 was normal (Fig. 2).

Figure 2. Symptoms, signs and histological result.

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Five patients had pain for less than 24 hours, 3 of these had an inflamed appendix, 1 had Meckel’s diverticulitis and 1 was normal. Seven patients had pain between 24 hours and 47 hours. Of these 4 had an inflamed appendix, 2 had a perforated appendix and 1 had a normal appendix. Three patients had pain for between 48 and 72 hours, all of whom had an inflamed appendix. Eight patients had pain for longer than 72 hours, of whom 4 had an inflamed appendix, 1 had a perforated appendix, 1 had Meckel’s diverticulitis, 1 had vermicularis and 1 had a normal appendix (Fig. 3).

Figure 3. Duration of abdominal pain and histological result

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Twenty patients (87%) had full blood count testing to assess their white cell and neutrophil count. Eighteen patients (78%) had their CRP levels checked. Seven patients had a normal white cell count (WCC). Of these, 1 had a normal appendix and 6 had an inflamed appendix. Thirteen patients had a raised WCC of which 3 had a normal appendix, 3 had a perforated appendix, 6 had an inflamed appendix and 1 had a Meckel’s diverticulitis. Two patients had a normal CRP of which 1 had an inflamed appendicitis and 1 had vermicularis. Of the 16 who had a raised CRP, 1 had a Meckel’s diverticulitis, 3 had a perforated appendix, 10 had an inflamed appendix and 2 had normal appendicies. The mean WCC for a perforated appendix was 19.5x103/μl(range 16.7 - 23.3). The mean WCC for an inflamed appendicitis was 16.4x103/μl (range 2.9 - 28.5).The mean WCC for a normal appendix was 17.2 x103/μl (range 15.5 - 19.6). When comparing abnormal with normal appendices, Fishers exact test confirmed that any variation was due to chance (P=0.13). The mean CRP for a perforated appendix was 68mg/L (range 24 – 93). The mean CRP value for an inflamed appendix was 115mg/L (range 5 – 262). The mean CRP value for a normal appendix was 10mg/L (range 5 - 13). Fishers exact test comparing normal with abnormal appendix CRP was significant (P=0.006), but comparing perforated to inflamed was not (P=0.39). Ultrasound (USS) was performed in 8 cases (35%). Of these, 6 patients had free fluid on scan of which 2 had a normal appendix, 1 had a perforated appendix and 3 had inflamed appendices, however 2 of these inflamed appendix had no free fluid at operation. The 2 patients who had no free fluid on USS both had an inflamed appendix and both had free fluid documented at operation. Five patients had a thickened appendix on USS suggestive of appendicitis. Three of these patients had an inflamed appendix, 1 had a perforated appendix and 1 had a normal appendix. Of the 3 patients whose appendix could not be visualized, 2 had an inflamed appendix and 1 had vermicularis.

The mean time to surgery was 16.3 hours (range 1.5 – 68.8hours). The average length of antibiotic course was 3.9 days (Range 1-6 days). The mean time to discharge was 4.4 days (range 1.6-7.4 days). One patient had a collection postop (4%) and 1 patient had an incisional hernia (4%).

Figure 4: Ultrasound finding of free fluid and histology

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Figure 5. Ultrasound finding of appendicitis and histology

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Discussion

Despite all the advances in modern surgery over the last century, acute appendicitis in the very young still presents a significant diagnostic challenge to the pediatric surgeon [1,2,3]. Delays in both presentation and diagnosis are frequent in this age group with a consequently high rate of morbidity and historically a significant rate of mortality [1,2,3]. Difficulties in communication from these young patients as well as the high incidence of gastroenteritis, upper respiratory tract infection, otitis media and UTI often confuse the diagnosis of appendicitis with the pain frequently being attributed to these other illnesses [3,4]. These delays have always been reported as leading to a high rate of perforation (40-89%) [4]. Interestingly our own perforation rate histologically is relatively low (13%), and this may be a reflection of a heightened awareness of recent times in a pediatric surgery tertiary referral unit. This low rate of perforation may also explain our relatively low rate of collection (4%). This reinforces the concept than an important factor in postoperative complication is rate of perforation. And so a key strategy in reducing morbidity would be to minimize the delay in diagnosis to reduce the rate of perforation. Despite the low perforation rate, our negative appendicectomy rate was also relatively low (13%). Meckel’s diverticulitis was an important differential diagnosis occurring in 8% of patients and should always be considered in the acute abdomen.

Certain symptoms and signs have been suggested as being more indicative of appendicitis [4], but in our series it would seem that the common symptoms and signs were broadly spread across the histological outcomes. Interestingly those with a normal appendix did not have diarrhea or vomiting and yet we know that these symptoms are common in other diagnoses. This is probably more a reflection of vigilant accurate assessment and so those with diarrhea and vomiting that did not have other signs consistent with appendicitis, never had their appendix removed. All but one inflamed/perforated patient had loss of appetite. It would suggest that this is a sensitive sign but not specific, and we would certainly not draw the conclusion that those with an appetite do not have appendicitis. Duration of pain also did not seem to indicate the likelihood of either having an inflamed or perforated appendicitis, which contradicts other reports [4]. Taken as a whole, this is consistent with appendicitis being a clinical diagnosis. The key to accurate diagnosis is based on history and examination by an experienced surgeon, and that no specific symptom or sign is key but an overall impression is made based on serial assessments [5,6]. This is the key to reducing delays in the very young and not focusing on specific symptoms and signs.

In this study, pre-operative white cell count does not appear to be particularly helpful in distinguishing a normal appendix from an abnormal appendix. However, the value of CRP does seem to be significantly raised in abnormal appendices (P=0.006), but in view of the small number of normal appendices we are hesitant to place too much emphasis on this result. As only one patient with a normal appendix had a ‘normal’ CRP we would face the problem of knowing at what level of raised CRP the likelihood of appendicitis is increased. This is complicated further by the fact perforated appendicitis had a lower CRP than inflamed. Ideally we would also need to know the CRP values of all the patients sent home without an operation. This would require far more patients than this study and to make it translatable to this patient group, the patients studied would need to be exclusively in this age group; a very difficult prospect. Inflamed appendices appear to have a higher CRP than the perforated but this is not statistically significant, but again accuracy of this analysis is limited by the small numbers involved. So for now CRP does not play a significant role in the diagnosis of appendicitis in the very young but remains an interest for research.

In our patient series, ultrasound did not appear to be particularly helpful as the diagnostic accuracy was poor; but this is an evolving imaging tool, both in terms of experience of radiologists and advances in ultrasound technology. There is already evidence of the usefulness of ultrasound in appendicitis [7,8] and so further work is needed in its use specifically in these young patients before conclusions can be made. In the US and parts of Europe, use of contrast computer tomography in adults is commonplace with positive and negative predictive values of over 85% and 99%. It’s utility in the pediatric population especially at this age, may well improve accurate diagnosis, but this benefit is paired with the significant risk of radiation exposure as well as a significant financial cost [1].

An important limitation of our data is that we were unable to reliably ascertain if patients had been given courses of oral antibiotics prior to presentation. Antibiotics given prior to presentation have been shown to result in delays in diagnosis with greater risk of perforation and complication as a consequence of the delay[9]. This group of young children, who are difficult to assess and often have concurrent illnesses, are at increased risk of being given antibiotics by community physicians prior to presentation to the surgeon, and therefore at risk of higher perforation rates and morbidity [10]. However, this fact strengthens the emphasis on history taking, serial clinical examination and early consideration of the diagnosis rather than changing a child’s management per se; and so is not a major limitation. It is always difficult when dealing with such small patient numbers to know how much significance to place on any findings. However, in view of the severe paucity of literature on appendicitis in the very young it is important to report what we can, to pool our experiences, to help aid the wider community in managing this challenging condition.

Conclusions

Diagnosis of appendicitis in the young child remains a significant diagnostic challenge despite advances in medical care. Diligent history taking and serial examination still play the vital role in accurately assessing these patients and the effectiveness of adjuncts such as blood tests and ultrasound as yet remain unproven. Minimizing the length of time to diagnosis and therefore to surgery is pivotal in decreasing perforation rates and its associated morbidity. The relatively low incidence of acute appendicitis in the very young child means that it is often overlooked and so a vigilant clinician with a high index of suspicion may contribute to earlier diagnosis and thereby reduce morbidity.

 

 

 

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