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Appendicitis in children with acute abdominal pain in primary care, a retrospective cohort study
Guus C G H Blok1, Laura M M Veenstra1, Johan van der Lei2
1Department of General Practice and Elderly Care Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.
Insights
General practitioners (GPs) miss nearly one-fifth of pediatric appendicitis cases. Specific physical exam findings, like rebound pain, are crucial for accurate diagnosis in children with abdominal pain.
Area of Science:
- Pediatric emergency medicine
- Primary care diagnostics
- Clinical epidemiology
Background:
- General practitioners (GPs) encounter diagnostic challenges with acute abdominal pain in children.
- Limited data exists on current diagnostic processes and accuracy of history/physical exams in primary care for pediatric abdominal pain.
Purpose of the Study:
- To delineate the diagnostic process for pediatric acute abdominal pain in primary care, specifically for appendicitis.
- To evaluate the diagnostic accuracy of individual clinical features in identifying appendicitis.
Main Methods:
- Retrospective cohort study in Dutch primary care (2010-2016) using the Integrated Primary Care Information database.
- Inclusion criteria: Children aged 4-18 with acute abdominal pain, no prior appendicitis history.
- Evaluation of GP management, diagnostic accuracy of clinical features, and pre-/post-test probabilities for appendicitis.
Main Results:
- 5.1% of 5691 children had appendicitis; 18.9% were initially misdiagnosed.
- Pre-test probabilities ranged from 3% (rigidity) to 28% (migratory pain).
- Post-test probabilities: Rebound pain (32.1%) and guarding (35.8%) were more accurate than overall GP assessment (29.6%). Negative right lower quadrant tenderness had 0.6% post-test probability.
Conclusions:
- GP assessment misses nearly one-fifth of pediatric appendicitis cases on initial presentation.
- Two-thirds of GP referrals for suspected appendicitis are negative.
- Specific physical examination signs significantly impact appendicitis likelihood, underscoring their importance.
Background:
General practitioners (GPs) face a diagnostic challenge when assessing acute abdominal pain in children. However, no information is available on the current diagnostic process or the diagnostic accuracy of history and physical examination in primary care settings.
Objective:
To describe the diagnostic process for acute abdominal pain among children in primary care, focusing on appendicitis, and to assess the diagnostic accuracy of individual clinical features.
Methods:
A retrospective cohort study in Dutch primary care, using the Integrated Primary Care Information database. Children aged 4-18 years were included if they had no history of appendicitis and presented with acute abdominal pain during 2010-2016. We evaluated GP management and the diagnostic accuracy of clinical features for appendicitis. Pre- and post-test probabilities were calculated for each clinical feature and compared with the probability of appendicitis after GP assessment.
Results:
Out of 5691 children, 944 (16.6%) were referred and 291 (5.1%) had appendicitis, of whom 55 (18.9%) were initially misdiagnosed. The pre-test probability (i.e. of appendicitis in evaluated children) varied from 3% (rigidity) to 28% (migratory pain). Concerning post-test probabilities, positive values for rebound pain (32.1%) and guarding (35.8%) and the negative value for right lower quadrant tenderness (0.6%) were superior to overall GP assessment (29.6% and 1.1%, respectively).
Conclusions:
GP assessment will miss almost one-fifth of children with appendicitis at their first presentation, and about two-third of GP referrals will be negative. The presence of specific signs can increase or decrease the likelihood of appendicitis, emphasising the importance of a physical examination.
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