Appendicitis in the young child: A continuing diagnostic challenge

Objective. The purpose of this review was to examine the presenting signs a nd symptoms of children 5 gears of age or less who underwent operation for appendicitis, in addition, we sought to determine the rate of perforation o f the appendix and the effect on outcome in this age group. Methods: Medical records for the period September 1987 to September 1998 we re reviewed for all children 5 years of age or less who underwent appendect omy for appendicitis. Data gathered included age at operation, gender, fare sought prior to admission for appendectomy. duration of symptoms, signs an d symptoms at the time of admission, and length of postoperative hospital s tay. Symptoms of diarrhea, emesis, fever, pain, and anorexia were recorded. Physical signs of an abdominal mass, guarding, rebound tenderness, rigidit y, and diffuse or focal tenderness were recorded. Diagnostic information in cluded white blood cell count with differential, and radiographic imaging, if obtained, The presence or absence of perforation of the appendix, and ab scess formation were based an the intraoperative impression of the operatin g surgeon. Results: For the 11-year period, 120 patients 5 years of age or less requir ed an operation for appendicitis and had a complete medical database. The m ean age was 3.6 +/- 1.3 years; 53% were male, Patients underwent a separate medical evaluation prior to arriving at a definitive diagnosis in 44.2% ca ses, The most common presenting symptom was abdominal pain (94%); the most common sign was abdominal tenderness (95.8%). Tenderness was generally diff use if perforation had occurred (62%) or focal in the nonperforated group ( 61%). The duration of symptoms in patients with perforation was more than d ouble that of the nonperforated patients (4.7 vs 2.1 days, respectively). T he mean white blood cell count (WBC) was 18.3 +/- 7.4 cells/mm(3), and did not differ significantly between the perforated and nonperforated groups. A left shift detected in the WBC differential was present in 91%. An abdomin al radiograph was obtained in 87%, and demonstrated a fecalith in 18%. ri p reoperative ultrasound was obtained in 38%, a computed tomographic scan in 7%. At the time of surgery, 74% were found to have evidence of perforation. An abscess was found at the initial surgery in 47% of patients with append iceal perforation, but in no patient in whom perforation had not occurred. The rate of perforation increased as the age of the patient decreased (100% perforation for age 1 (n = 10) to 69% for age 5, (n = 35), Perforation mas associated with a longer hospital length of stay as compared to the nonper forated appendix (median 9 days vs. 3 days, respectively, P < 0.001), There were no deaths in this series. Conclusion: Appendiceal perforation continues to be a common occurrence in the young child and increases in frequency as the age of the patient decrea ses and the duration of symptoms lengthens. Perforation results in a signif icant increase in hospital length of stay and rate of abscess formation.