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Acute appendicitis: the continuing role for active observation
P Bachoo1, A A Mahomed, G K Ninan
1Department of Surgical Paediatrics, Royal Aberdeen Children's Hospital, Cornhill Road, Aberdeen AB25 2ZG, UK.
Insights
Active observation for suspected acute appendicitis (AA) is a valid diagnostic strategy. This 6-year review found that observation does not increase patient morbidity, ensuring accurate diagnosis and successful outcomes.
Area of Science:
- Pediatric Surgery
- Emergency Medicine
- Diagnostic Accuracy
Background:
- Acute appendicitis (AA) is a common surgical emergency in children.
- Diagnostic uncertainty in suspected AA can lead to delayed treatment or unnecessary surgery.
- Active observation is a strategy employed when AA diagnosis is uncertain.
Purpose of the Study:
- To evaluate the safety and efficacy of an active observation policy for children with suspected acute appendicitis.
- To determine if active observation increases patient morbidity.
- To assess the diagnostic accuracy and outcomes associated with this policy.
Main Methods:
- Prospective data collection over a 6-year period.
- Inclusion of 1,479 children admitted with suspected acute appendicitis.
- Analysis of clinical diagnosis, observation duration, surgical intervention, and patient outcomes.
Main Results:
- 69.5% of patients were discharged with non-specific abdominal pain after observation.
- 72% of confirmed AA cases underwent surgery on admission; 28% had delayed surgery due to diagnostic doubt.
- Positive predictive value of clinical assessment was 97.9%, with a 2.6% normal appendicectomy rate.
- No mortality was observed; surgical morbidity was 6% and not correlated with surgery timing.
Conclusions:
- Active observation is a valid and safe policy for managing suspected acute appendicitis in children.
- This approach leads to accurate diagnosis and successful patient outcomes without increased morbidity.
- The policy supports appropriate surgical intervention while avoiding unnecessary procedures.
Abstract:
We present the results of a 6-year review of appendicitis. In the event of diagnostic doubt, a policy of active observation was instituted. This review endorses the validity of such a policy, indicating that it does not expose patients to increased morbidity. Data were collected prospectively over a 6-year period on 1,479 children admitted with suspected acute appendicitis (AA); 1,028 (69.5%) were discharged with a diagnosis of non-specific abdominal pain after a mean observation period of 2.5 days, whilst in the remaining 451 a clinical diagnosis of AA was confirmed. The male-to-female ratio was equal, with no difference in the mean age of males (11 years) or females (12 years); 95% of patients were over the age of 5 years. In 324 (72%) cases surgery was performed on the day of admission, whilst in the remaining 126 (28%) it was deferred for 1 to 6 days because the clinical diagnosis of AA remained doubtful. The mean hospital stay was 4 days (range 1-32). Analysis of the histological reports of all 451 cases confirmed a positive predictive value for clinical assessment alone of 97.9% and a normal appendicectomy rate of 2.6%. No mortality was observed; surgical morbidity was recorded at 6% with no correlation between postoperative morbidity and timing of surgery evident (Spearmans correlation coefficient = -0.079, p = 0.9). Active observation for suspected AA thus remains a valid technique for achieving an accurate diagnosis and successful outcome.