Suspected Pediatric Appendicitis Management in the Emergency Department: A Prospective Observational Study in an...

Abdominal pain is a common pediatric presentation in the emergency department (ED), and acute appendicitis (AA) is the most common surgical diagnosis. This study describes the management of suspected AA in a tertiary Australian pediatric ED.

A single-center prospective observational study was performed between November 2022 and May 2023. Children aged 5 to 15 years presenting to the ED with acute abdominal pain and clinician suspicion of AA were included. Clinical gestalt was measured using a 5-point Likert Scale before and after blood tests. Diagnosis of AA was confirmed on histopathology, and non-AA was confirmed with follow-up at 30 to 60 days.

The study enrolled 481 children; AA was diagnosed in 146 (30.6%). Patients with AA were older (11.1 vs. 10.0 y) and more likely to be male (69.2% vs. 48.1%) compared with those without AA. Blood tests were performed in 449 (93.3%) children, with higher rates in AA cases (100% vs. 90.4%). Gestalt improved with blood test results, with overall diagnostic accuracy increasing from 65.9% pre-blood tests to 88.5% post-blood tests. Ultrasound (US) was performed in 361 (75.1%) children with a diagnostic accuracy of 90.6% and was frequently used even in patients deemed low-risk post-blood tests (65.7%). One hundred and fifty (31.2%) of suspected AA cases underwent surgery, with 3 negative appendectomies and 1 ovarian cystectomy without appendectomy. Median (IQR) hospital length of stay was significantly longer for AA cases than non-AA cases [50.8 (35.3 to 95.0) h vs. 7.1 (4.6 to 16.8) h].

This study reviews the management and outcomes of suspected AA in a high-volume Australian ED. It shows the importance of blood tests in improving diagnostic accuracy of clinician gestalt and highlights the potential overuse of US in low-risk patients. Future research should explore a more structured diagnostic approach to increase diagnostic accuracy, optimize resource utilization, and improve patient outcomes.