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Acute appendicitis: is there a difference between children and adults?
1Department of Surgery, Kaiser Permanente, Los Angeles Medical Center, 4760 Sunset Boulevard, 3rd Floor, Los Angeles, CA 90027, USA.
Insights
Diagnosing acute appendicitis in children is similar to adults, with migratory pain and high white blood cell count being key indicators. Perforation and morbidity rates are comparable between pediatric and adult patients.
Area of Science:
- Pediatric Surgery
- Gastroenterology
- Emergency Medicine
Background:
- Acute appendicitis diagnosis is challenging in children due to atypical symptoms and delayed presentation, historically leading to higher perforation rates.
- Despite challenges, pediatric appendicitis generally has lower morbidity compared to adults.
Purpose of the Study:
- To compare clinical presentation, diagnostic indicators, and outcomes of acute appendicitis in pediatric versus adult patients.
- To evaluate if delayed presentation impacts perforation rates in children.
Main Methods:
- Retrospective review of 210 pediatric (≤13 years) and 744 adult appendectomy cases (January 1995-December 2000).
- Comparison of presentation duration, prior evaluations, imaging use (CT/ultrasound), emergency room evaluation time, and observed cases.
- Analysis of diagnostic clues including classic migratory pain and white blood cell (WBC) count.
Main Results:
- Pediatric patients had similar pain duration and imaging use but shorter emergency room evaluation times compared to adults.
- Classic migratory pain (94.2% vs 89.6%) and elevated WBC count (> or =12 x 10^9/L) (91.5% vs 84.3%) were highly predictive in both groups.
- Negative appendectomy rates were lower in children (10.0% vs 19.0%), while perforation rates were similar (19.0% vs 13.8%).
- Pediatric perforation was not linked to delayed presentation; mortality and morbidity were comparable between age groups.
Conclusions:
- Contrary to traditional beliefs, acute appendicitis diagnosis and presentation are similar in children and adults.
- Migratory pain, physical findings, and leukocytosis are reliable diagnostic markers for appendicitis in both pediatric and adult populations.
- Appendicitis outcomes, including perforation and morbidity, are comparable between children and adults, irrespective of presentation delay.
Abstract:
Historically, the lack of classic symptoms and delay in presentation make diagnosing acute appendicitis more difficult in children, resulting in a higher perforation rate. Despite this, the morbidity of acute appendicitis is usually lower in children. We evaluated the current differences in clinical presentation, diagnostic clues, and the outcomes of acute appendicitis between the two age groups. A retrospective review of 210 consecutive cases of pediatric appendectomy and 744 adult cases for suspected acute appendicitis from January 1995 to December 2000. Pediatric patients were defined as being 13 years and younger. Pediatric patients were similar to adult patients with respect to duration of pain before presentation (2.4 +/- 4.3 days vs 2.5 +/- 7.3 days), number of patients previously evaluated (22.0 vs 17.7%), number of imaging tests (computed tomography or ultrasound; 32.9 vs 40.2%), and number of patients observed (16.7 vs 17.2%). However, pediatric patients required less time for emergency room evaluation (4.0 +/- 2.7 hours vs 5.7 +/- 4.9 hours, P = 0.0001). In children and adults, a history of classic, migrating pain had the highest positive predictive value (94.2 vs 89.6%), followed by a white blood cell count > or =12 x 109/L (91.5 vs 84.3%). The overall negative appendectomy rate was 10.0 per cent for children and 19.0 per cent for adults (P = 0.003); the perforation rate was 19.0 per cent and 13.8 per cent, respectively (P > 0.05). The perforation rate in children was not associated with a delay in presentation (perforated cases, 2.9 +/- 3.3 days compared with nonperforated cases, 2.3 +/- 4.6 days). Mortality and morbidity, including wound infection rate and intra-abdominal abscess rate, were similar. Contrary to traditional teaching, diagnosing acute appendicitis in children is similar to that in adults. A history of migratory pain together with physical findings and leukocytosis remain accurate diagnostic clues for children and adults. Perforation rate and morbidity in children is similar to those in adults. The outcomes of acute appendicitis in children are not associated with a delay in presentation or delay in diagnosis.
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