Overnight Decision-Making for Equivocal Appendicitis Often Involves Unnecessary Hospital Admissions

After-hours surgical consultations for equivocal appendicitis are common in children's hospitals. When surgery is not clearly indicated, disposition options include hospital admission with serial examinations (ASE) or discharge with return precautions. In our hospital, ASE occurs exclusively after-hours. The purpose of this study is to characterize the benefits and harms of overnight ASE for equivocal appendicitis.

We conducted a single-institution retrospective review of patients less than 18 ys old evaluated overnight for suspected appendicitis from July 2021 to July 2023. The definition of equivocal appendicitis was considered to be nondefinitive imaging as determined by the attending radiologist and overnight surgical resident. Analyzed groups included ASE versus discharged patients.

There were 43 (54%) patients in the ASE group and 36 (46%) discharged patients. Ten ASE patients underwent appendectomy with 3 (30%) showing no inflammation on pathology (negative appendectomy). One (3%) discharged patient represented ultimately undergoing a negative appendectomy. ASE patients without appendicitis had higher Alvarado scores compared to discharged patients (4.0 versus 3.0, P value = 0.004). An Alvarado score less than 5 ruled out appendicitis in 100% of cases; however, 44% of these patients were admitted.

Children with equivocal appendicitis presenting after-hours are often admitted to the hospital, despite low Alvarado scores. Children in this study offered ASEs for equivocal appendicitis have unexpectedly high negative appendectomy rates. Conversely, patients with low Alvarado scores who are discharged rarely present for subsequent intervention. Discharging patients with equivocal appendicitis and low Alvarado score may reduce resource utilization without increasing risks of missed diagnosis.