Original Article

The Presentation of Appendicitis in Preadolescent Children Joshua M. Colvin, MD,* Richard Bachur, MD,y and Anupam Kharbanda, MDz

Purpose: We describe the clinical presentation of appendicitis in preadolescent children and differences in symptoms among agestratified subgroups. Methods: This is a retrospective analysis of a prospectively collected de-identified data set of patients 3 years or older and patients younger than 12 years presenting to a pediatric emergency department during a 21-month period with symptoms suspicious for appendicitis. The rates of appendicitis, perforation, negative appendectomy, as well as sensitivities, specificities, and positive likelihood ratios for historical and clinical variables associated with appendicitis were calculated for the entire cohort and for 3 agestratified subgroups. Results: Of 379 children, 121 (32%) had appendicitis, 75 (62%) were male, 24 (20%) had a perforated appendix, and 16 (12%) had a negative appendectomy. The perforation rate was highest (53%) in the youngest subset of patients (3Y5.99 years). Patients with appendicitis presented with inability to walk (82%), maximal right lower quadrant tenderness (82%), nausea (79%), pain with percussion, hopping, coughing (79%), and anorexia (75%). Fewer patients with appendicitis presented with a history of vomiting (66%), fever (47%), or diarrhea (16%), and these findings were not associated with the diagnosis. The youngest subset of patients (3Y5.99 years) presented to the emergency department with fever; however, within this age subset, there was no significant difference in temperatures between patients with and without appendicitis. Fever was an indicator for perforation. Psoas, Rovsing, and obturator signs were infrequent but very specific for appendicitis (0.86Y0.98 depending on age). Conclusions: Nausea, right lower quadrant tenderness, inability to walk, and elevated white blood cell and neutrophil counts are sensitive indicators of appendicitis in preadolescent children. Although peritoneal signs are infrequently elicited, when present, they substantially increase the likelihood of appendicitis. Fever, vomiting, and diarrhea are not associated with appendicitis in preadolescent children. Key Words: appendicitis, acute abdominal pain

*Department of Pediatrics, Morgan Stanley Children’s Hospital, Columbia University, New York, NY; yDepartment of Pediatrics and Division of Pediatric Emergency Medicine, Children’s Hospital, Harvard Medical School, Boston, MA; and zDepartment of Pediatrics and Division of Pediatric Emergency Medicine, Morgan Stanley Children’s Hospital, Columbia University, New York, NY. Address correspondence and reprint requests to Joshua M. Colvin, MD, Department of Pediatrics and Division of Pediatric Emergency Medicine, One Children’s Place, St. Louis, MO 63110. E-mail: jc2506@ columbia.edu. Copyright * 2007 by Lippincott Williams & Wilkins ISSN: 0749-5161/07/2312-0849

A

ppendicitis remains a challenging diagnosis in children.1Y3 As a consequence, initial misdiagnosis rates for children younger than 12 years range from 28% to 57%.3 The difficulty in diagnosis has been attributed to a large overlap of symptoms with many other common childhood illnesses, such as acute gastroenteritis, urinary tract infection, and constipation.3Y5 In addition, the diagnosis of appendicitis in young children is often not consistent with the classical description for appendicitis in adolescents and adults.6 The difference in presentation of appendicitis in young children has been attributed to their inability to accurately describe their symptoms.3,7 This results in children presenting to emergency departments (EDs) or primary care providers multiple times before the diagnosis of appendicitis is made, leading to delays in diagnosis and subsequent increased perforation rates. Several studies have described the atypical nature in which young children present with appendicitis. Researchers have highlighted items such as diarrhea, nonspecific peritoneal signs, and normothermia as being more common in young children with appendicitis.6 However, prior studies were limited by small sample sizes, cohorts that included adults, or retrospective study designs.2,5,6,8Y10 In this study, we describe a large cohort of young children with appendicitis to help elucidate their clinical presentation and agedependent variability.

METHODS Data Set We conducted a secondary review of a de-identified database of children and adolescents 3 to 21 years of age with acute abdominal pain. The database was prospectively collected over 21 consecutive months at an urban, tertiary care, pediatric ED that has approximately 52,000 visits per year. A low-risk clinical decision rule was previously published on a subset of the study population.11

Study Population Patients were eligible for entry into the study if a pediatric emergency medicine (PEM) attending had a suspicion for appendicitis such that they consulted a surgeon to evaluate for possible appendicitis. Children’s Hospital Boston has a clinical practice guideline in place that requires surgical consultation before obtaining advanced imaging (computed tomography or ultrasound) for appendicitis. Patients were excluded from the study if they had undergone prior abdominal surgery, had radiologic imaging studies

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within the previous 2 weeks, suffered from chronic medical conditions, or were pregnant. The PEM attending responsible for the patient’s care completed standardized data collection forms consisting of 24 demographic, historical, and physical examination variables before diagnostic imaging and independent of the surgeon’s evaluation. When diagnostic imaging was ordered, the study coordinator was contacted by the radiologist on duty who subsequently paged the PEM attending responsible for the patients care to ensure that the data form was completed before obtaining imaging results. Data were also gathered from laboratory, radiology, pathology, and operative reports. Final diagnosis was determined by pathological report if the patient had abdominal surgery or by follow-up telephone if the patient had no operative diagnosis. The capture rate for the study period was 92%.

interpreted as significant. However, when multiple categorical variables were compared, we used a Bonferroni adjustment and used a P value of 0.003 (0.05/17 comparisons) as our cutoff for significance. We calculated sensitivity, specificity, positive likelihood ratios, and their 95% confidence intervals for all categorical clinical variables.

RESULTS Study Population

The initial study was approved by the Children’s Hospital Boston committee on clinical investigations and was Health Insurance Portability and Accountability Act compliant. Informed consent was obtained from all participating PEM physicians and from all parents, and assent was obtained from children who were older than 7 years before the collection of data. The Columbia University Medical Center’s committee on clinical investigations granted an exemption for the current study because it is a secondary analysis of a de-identified database and posed no more than minimal risk to patients.

We identified 379 patients between the ages 3 and 11.99 years who presented to the ED with the chief complaint of acute abdominal pain and who had a surgical consultation for possible appendicitis. Appendicitis was confirmed in 121 (32%) of the patients. Eighty three percent of patients with appendicitis presented to the ED within 48 hours of the initiation of their symptoms. The mean age was 8.2 years (standard deviation T 2.4 years). A total of 84 patients were between 3 and 5.99 years, 134 between 6 and 8.99 years, and 161 between 9 and 11.99 years, respectively. Seventy-five (62%) of the 121 patients with appendicitis were male. Overall, 24 (20%) of the 121 patients with appendicitis had a perforated appendix. The youngest subgroup had significantly fewer cases of appendicitis but had an increased rate of perforation as compared to the older subgroups (Table 1). The most frequent diagnoses for patients who did not have appendicitis were nonspecific abdominal pain (40%), acute gastroenteritis (27%), constipation (12%), and mesenteric adenitis (8%).

Study Design

Clinical Course and Disposition

For the purpose of the current study, we focused on children 3 years or older and children younger than 12 years. Appendicitis rate, perforation rate, and negative appendectomy rate for the study population, as well as for 3 subgroups stratified by age, were calculated. Frequencies of historical variables, physical examination findings, and laboratory data of patients with appendicitis were compared to those of patients without appendicitis and among age-stratified subgroups. Chi-square testing or Fisher exact test was used for categorical variables, and the Student t test was used for continuous variables (SPSS 13.0; SPSS Inc, Chicago, Ill). For comparison of variables, a P values less than 0.05 was

After examination by the PEM attending, 318 (84%) patients underwent diagnostic imaging. Computed tomography was performed on 266 (70%), ultrasound on 106 (28%), and both CT and ultrasound on 54 (14%) patients. There was a significant difference in CT utilization among the 3 age groups (Table 1). After evaluation, 197 (52%) patients were discharged from the hospital, 131 (35%) went directly to the operating room, and 51 (13%) were admitted for observation. Six patients who were discharged from the hospital ultimately underwent an appendectomy, 3 of whom had appendicitis. Sixteen patients who were taken to the operating room had a normal appendix, for a negative

Consent and Study Approval

TABLE 1. Demographics of Patients Presenting With Appendicitis

Total number of patients Age, y Mean (TSD) Ultrasound, % CT, % Total imaging, % Appendicitis, % Perforated appendicitis, % Normal pathology after appendectomy, % Gender (males) with appendicitis, %

850

Overall

3Y5.99 y

6Y8.99 y

9Y11.99 y

379 3Y11.99 8.2 (2.4) 106 (28) 266 (70) 318 (84) 121 (32) 24 (20) 16 (12) 75 (62)

84

134

161

35 (26) 95 (70) 113 (84) 42 (31) 9 (21) 3 (7) 25 (60)

33 (21) 125 (77) 139 (86) 64 (40) 7 (11) 10 (16) 43 (67)

38 46 66 15 8 3 7

(46) (56) (80) (18) (53) (17) (47)

P

0.434 0.003 0.472 0.003 0.001 0.412 0.311

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appendectomy rate of 12%. Negative appendectomies were equally distributed across the 3 age subgroups.

Clinical Characteristics of the Overall Study Population We compared laboratory data, historical data, and physical examination findings of patients diagnosed with appendicitis versus those with acute abdominal pain of another etiology (Table 2). All clinical variables except for history of emesis, anorexia, diarrhea, and temperature in the ED or a fever (Q38-C) at home were strongly associated with appendicitis (P G 0.003).

Clinical Presentation of Appendicitis by Age We evaluated laboratory data, historical data, and physical examination findings of patients with appendicitis by age-stratified groups (Tables 3Y5). In the youngest subset, a majority of patients with appendicitis (83%) had a history of fever (Q38-C) at home, and their mean temperature at presentation to the ED was 38.1-C. However, a history of fever was not significantly different between patients with appendicitis and those without appendicitis in all age groups (P = 0.50Y0.94). History of fever at home was more common in patients with perforated (76%) versus non-

Appendicitis in Preadolescent Children

perforated appendicitis (39%) (P = 0.002). Mean temperature in the ED was also higher for patients with perforated appendicitis (38.0-C) versus nonperforated appendicitis (37.2-C) (P = 0.001). Significant differences were found between age groups for history of focal right lower quadrant (RLQ) pain, history of migration of pain, and diarrhea (Table 3), maximal tenderness in the RLQ, rebound tenderness, pain with percussion, hopping or coughing, body temperature (Table 4), absolute neutrophil count, and percentage of neutrophils (Table 5). The positive likelihood ratios for historical data were highest for duration of pain 9 24 hours, history of maximal pain at RLQ, and migration of pain (Table 3). The positive likelihood ratios for physical examination data were highest for rebound tenderness, psoas sign, Rovsing sign, and obturator sign (Table 4).

DISCUSSION In this evaluation of nearly 400 children younger than 12 years with acute abdominal pain, we found that nausea, maximal pain in the RLQ, and the inability to walk were all highly associated with appendicitis. These findings are consistent with previous findings in pediatric and adult cohorts.12 However, common teaching is that migration of pain to the RLQ and positive Rovsing, psoas, or

TABLE 2. Clinical Characteristics of Preadolescent Patients With Acute Abdominal Pain (n = 379) Clinical Variable History, n (%) Duration of pain 9 24 h Nausea History of focal RLQ pain History of migration of pain to RLQ Anorexia Emesis Diarrhea Fever at home (Q38-C) Physical examination, n (%) Unable to walk or walks with a limp Maximal tenderness at RLQ Guarding Rebound tenderness Pain with percussion, hopping, cough Psoas sign Rovsing sign Bowel sounds (decreased/absent) Obturator sign ED temperature, mean -C (SD) Laboratory data WBC, n = 103/6L, mean (SD) ANC, n = 103/6L, mean (SD) Neutrophils, % (SD)

Complete Data

Appendicitis

No. Appendicitis

P

(68) (79) (74) (39) (75) (66) (16) (47)

102 223 126 59 130 120 45 118

(45) (59) (50) (24) (58) (56) (21) (53)

G0.001 G0.001 G0.001 G0.001 0.003 0.087 0.276 0.307

(93) (86) (87) (98) (91) (78) (81) (74) (76) (99)

93 (82) 84 (82) 68 (65) 56 (47) 81 (79) 27 (30) 24 (26) 31 (36) 20 (23) 37.4 (1.0)

107 124 99 51 94 21 21 24 15 37.4

(45) (55) (44) (20) (39) (10) (10) (12) (7) (1.0)

G0.001 G0.001 G0.001 G0.001 G0.001 G0.001 G0.001 G0.001 G0.001 0.689

377 (99) 355 (94) 355 (94)

16.5 (5.7) 14.2 (5.5) 82 (8.5)

12.2 (6.2) 9.5 (6.7) 72 (15.3)

334 325 374 364 325 318 321 327

(88) (86) (99) (96) (86) (84) (85) (86)

353 329 330 373 344 297 308 282 289 377

71 81 90 45 76 67 16 48

G0.001 G0.001 G0.001

Significance assessed at P G 0.003 secondary to multiple comparison. WBC indicates white blood cell count.

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TABLE 3. Historical Findings in Patients With Appendicitis by Age Historical Data Duration of pain 9 24 hours 3Y5.99 y 6Y8.99 y 9Y11.99 y Nausea 3Y5.99 y 6Y8.99 y 9Y11.99 y Anorexia 3Y5.99 y 6Y8.99 y 9Y11.99 y Migration of pain 3Y5.99 y 6Y8.99 y 9Y11.99 y History of focal RLQ pain 3Y5.99 y 6Y8.99 y 9Y11.99 y Diarrhea 3Y5.99 y 6Y8.99 y 9Y11.99 y Emesis 3Y5.99 y 6Y8.99 y 9Y11.99 y Fever at home (Q38-C) 3Y5.99 y 6Y8.99 y 9Y11.99 y

Sensitivity (CI 95%)

Specificity (CI 95%)

+LR

P

0.77 (0.46Y0.94) 0.63 (0.46Y0.78) 0.69 (0.54Y0.80)

0.64 (0.51Y0.76) 0.56 (0.44Y0.67) 0.49 (0.39Y0.60)

2.13 1.44 1.36

NS

0.75 (0.43Y0.93) 0.88 (0.72Y0.96) 0.75 (0.61Y0.85)

0.46 (0.34Y0.59) 0.34 (0.24Y0.46) 0.43 (0.32Y0.54)

1.39 1.33 1.31

NS

0.92 (0.62Y1.0) 0.88 (0.71Y0.96) 0.64 (0.50Y0.76)

0.40 (0.28Y0.53) 0.45 (0.34Y0.57) 0.40 (0.30Y0.52)

1.53 1.61 1.07

NS

0.33 (0.11Y0.65) 0.37 (0.23Y0.53) 0.43 (0.30Y0.60)

0.87 (0.76Y0.93) 0.72 (0.61Y0.81) 0.73 (0.62Y0.81)

2.48 1.30 1.56

0.013

0.73 (0.45Y0.91) 0.74 (0.58Y0.86) 0.75 (0.62Y0.85)

0.68 (0.55Y0.78) 0.43 (0.33Y0.54) 0.43 (0.32Y0.54)

2.27 1.29 1.34

0.001

0.07 (0.00Y0.38) 0.18 (0.07Y0.35) 0.16 (0.08Y0.29)

0.94 (0.84Y0.98) 0.78 (0.66Y0.86) 0.70 (0.59Y0.79)

1.19 0.79 0.54

0.006

0.75 (0.43Y0.93) 0.71 (0.52Y0.84) 0.61 (0.47Y0.73)

0.45 (0.32Y0.58) 0.36 (0.25Y0.47) 0.53 (0.41Y0.64)

1.36 1.09 1.28

NS

0.83 (0.51Y0.97) 0.53 (0.35Y0.70) 0.35 (0.23Y0.49)

0.29 (0.22Y0.37) 0.46 (0.35Y0.58) 0.64 (0.53Y0.74)

0.88 0.98 0.98

0.00

+LR indicates positive likelihood ratio; NS, not significant (P 9 0.05).

obturator sign are also frequent findings in patients with appendicitis.13 We found that among children with appendicitis, the psoas, obturator, and/or Rovsing signs were infrequently elicited. As a result, the sensitivities of these findings were not adequate to diagnose appendicitis. This differs significantly from the findings by Marrero et al,9 who reported that children with appendicitis presented with Rovsing sign in 92% and the psoas sign in 80%. The unusually high rates of the Rovsing and psoas signs in the study by Marrero et al9 were likely related to the fact that these physical examination findings were only documented to be present in 15 of 42 charts (33%), making the actual rate of these findings impossible to determine. Clearly, when these physical signs are present, the diagnosis of appendicitis is significantly more likely. Across age subgroups, the historical findings that were most sensitive for appendicitis were nausea, anorexia, and

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history of RLQ pain. Several authors have examined the frequencies of these variables. In the largest of these studies, Williams et al14 reported on children younger than 15 years with appendicitis, 81% had nausea, 77% vomiting, and 66% anorexia. Nelson et al15 examined children younger than 12 years with appendicitis and found that 84% of children presented with anorexia. Similarly, Marrero et al9 published a retrospective record review of 42 patients younger than 12 years diagnosed with appendicitis. In this study, 88% had both nausea and vomiting, and 86% reported anorexia. Several other authors, including O’Shea et al16 and Reynolds and Jaffe,17 have commented on the strong association between vomiting and appendicitis. In contrast to these studies, we found vomiting to be frequent (66%) among patients with appendicitis, but vomiting was also common in patients without appendicitis (56%), giving this variable low specificity for appendicitis. It is likely that our findings * 2007 Lippincott Williams & Wilkins

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Appendicitis in Preadolescent Children

TABLE 4. Clinical Examination Findings in Patients With Appendicitis by Age Physical Examination Unable to walk, or walks with a limp 3Y5.99 y 6Y8.99 y 9Y11.99 y Maximal tenderness at RLQ 3Y5.99 y 6Y8.99 y 9Y11.99 y Guarding 3Y5.99 y 6Y8.99 y 9Y11.99 y Rebound tenderness 3Y5.99 y 6Y8.99 y 9e12 y Pain with percussion, hopping, cough 3Y5.99 y 6Y8.99 y 9Y11.99 y Psoas sign 3Y5.99 y 6Y8.99 y 9Y11.99 y Rovsing sign 3Y5.99 y 6Y8.99 y 9Y11.99 y Bowel sounds (decreased/absent) 3Y5.99 y 6Y8.99 y 9Y11.99 y Obturator sign 3Y5.99 y 6Y8.99 y 9Y11.99 y

ED temperature, -C (SD) 3Y5.99 y 6Y8.99 y 9Y11.99 y

Sensitivity (CI 95%)

Specificity (CI 95 %)

+LR

P

0.73 (0.45Y0.91) 0.93 (0.79Y0.98) 0.72 (0.59Y0.82)

0.57 (0.44Y0.69) 0.51 (0.40Y0.62) 0.58 (0.47Y0.68)

1.71 1.90 1.70

NS

0.85 (0.54Y0.97) 0.76 (0.57Y0.88) 0.84 (0.72Y0.92)

0.53 (0.40Y0.66) 0.46 (0.35Y0.58) 0.38 (0.28Y0.49)

1.81 1.41 1.35

0.020

0.77 (0.46Y0.94) 0.79 (0.62Y0.91) 0.54 (0.41Y0.67)

0.53 (0.40Y0.66) 0.53 (0.41Y0.64) 0.61 (0.50Y0.71)

1.64 1.67 1.40

NS

0.50 (0.24Y0.76) 0.62 (0.46Y0.76) 0.37 (0.25Y0.50)

0.88 (0.78Y0.95) 0.79 (0.69Y0.87) 0.74 (0.64Y0.82)

4.31 2.96 1.42

0.025

0.80 (0.44Y0.96) 0.89 (0.74Y0.96) 0.73 (0.59Y0.83)

0.70 (0.57Y0.80) 0.66 (0.55Y0.75) 0.51 (0.40Y0.61)

2.65 2.57 1.47

0.009

0.44 (0.15Y0.77) 0.39 (0.22Y0.59) 0.23 (0.13Y0.37)

0.94 (0.84Y0.99) 0.90 (0.81Y0.96) 0.86 (0.77Y0.93)

8.00 4.10 1.67

NS

0.33 (0.09Y0.69) 0.37 (0.21Y0.56) 0.19 (0.10Y0.32)

0.90 (0.82Y0.98) 0.90 (0.80Y0.95) 0.88 (0.78Y0.94)

4.83 3.53 1.55

NS

0.42 (0.17Y0.71) 0.52 (0.32Y0.71) 0.26 (0.14Y0.41)

0.85 (0.71Y0.93) 0.92 (0.82Y0.97) 0.86 (0.76Y0.93)

2.71 6.22 1.86

NS

0.33 (0.09Y0.69) 0.32 (0.17Y0.52) 0.16 (0.08Y0.30)

0.98 (0.87Y1.0) 0.90 (0.80Y0.96) 0.91 (0.82Y0.96)

17.67 3.21 1.83

NS

Mean

SD

P

38.1 37.5 37.1

1.1 0.9 0.9

0.001

+ LR indicates positive likelihood ratio; NS, not significant (P 9 .05).

differed from prior research because the prevalence of appendicitis in our population (32%) was markedly higher than many of these previous studies. We found that the physical examination findings of maximal tenderness in the RLQ, the inability to walk or walks with a limp, and pain with percussion/coughing/

hopping had the highest sensitivity for appendicitis. These results are consistent with other authors who have reported on frequencies of physical examination findings in appendicitis patients. For example, Rappaport et al18 conducted a retrospective analysis of 77 patients younger than 7 years who underwent appendectomy during a 10-year period. In

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TABLE 5. Laboratory Findings in Patients With Appendicitis by Age Laboratory Data

Mean

SD

P

17.5 17.6 15.6

5.5 5.7 5.6

NS

16.2 15.5 13.1

4.0 5.4 5.4

0.042

4.0 4.9 10.1

.033

3

WBC, n = 10 /6L 3Y5.99 y 6Y8.99 y 9Y11.99 y ANC, n = 103/6L 3Y5.99 y 6Y8.99 y 9Y11.99 y Neutrophils, % 3Y5.99 y 6Y8.99 y 9Y11.99 y

85 84 80

ANC indicates absolute neutrophil count; WBC, white blood cell count; NS, not significant (P 9 0.05).

this study, the most frequent physical examination finding was RLQ tenderness (90%). Graham et al19 retrospectively reviewed 155 charts of patients younger than 6 years presenting for appendectomy. Ninety-five percent of children presented with abdominal tenderness and 75% with rebound tenderness. We also explored atypical features in appendicitis such as presence of fever and diarrhea. As opposed to previous studies, we found that a history of fever at home (Q38-C), although present in 47% of patients with appendicitis, was not a reliable diagnostic indicator of appendicitis. We also found no significant difference between mean body temperatures of patients presenting to the ED with appendicitis and those without appendicitis. O’Shea et al16 reported a sensitivity (0.75) and specificity (0.78) for fever in children with appendicitis. The different outcomes between theses studies may be explained by differences in sample size, enrollment criteria, or definitions of fever. We did find that the youngest subgroup presented to the ED with a mean temperature of 38.1-C and that fever was associated with appendiceal perforation. However, the youngest patients who did not have appendicitis also had high rates of fever. Overall diarrhea was a rare finding (16%) in our study and not found to be associated with appendicitis. In the preschool age group, diarrhea was surprisingly rare among patients with appendicitis (7%). This is much lower than the previously reported rates of 32 % by Nance et al2 and 46% by Sakellaris et al.6 Given the small numbers of patients in this youngest age group in each of these studies, it is difficult to draw comparisons. The overall appendiceal perforation rate in our data set was 20%, with the highest rate (53%) occurring in the 3- to 5.99-year subgroup. This is consistent with other published reports that have documented perforation rates of 20% to 100% in children younger than 5 years. Clearly, the diagnosis of appendicitis in the very young (G5 years) remains quite challenging. Recently, several authors have

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reported on their experiences with this age group. The largest of these studies was published by Nance et al, who reported on 132 preschool children (G5 years) with appendicitis.2 They found that these young children with appendicitis presented with pain in 94%, fever in 80% (temperature over 38.5-C), vomiting in 83%, anorexia in 74%, guarding in 72%, diffuse tenderness in 56%, and diarrhea in 32%. In a more recent study, Sakellaris et al6 examined 122 patients younger than 5 years and found that 94% of patients had abdominal pain; 90%, fever (temperature 9 37-C); 86%, nausea and vomiting; 81%, rebound tenderness; 68%, guarding; 54%, decreased or absent bowel sounds; and 46%, diarrhea. The acute nature of these children’s presentation is likely related to the fact that they present with a perforated appendix. In general, our data for the youngest children support the findings of Nance and Sakellaris. In addition, our results would support clinicians, increasing their suspicion for appendicitis in children who have abdominal pain 9 12 hours and anorexia and not using the absence of rebound pain, the psoas, obturator, or Rovsing sign as a reliable parameters to rule out appendicitis. One interesting observation during our study was that the perforation rate in the preschool age children remained high (53%) despite frequent use of diagnostic imaging (80%). Given the literature on the benefits of CT, we would have expected a significant reduction in the rate of perforation, compared to the pre-CT era. In fact, the perforation rate does not seem to have changed significantly; in 1980 Graham et al19 reported a 63% perforation rate in their preschool age cohort. In addition, recently Flum et al20 published a population-based analysis that reveals that despite modern imaging, the perforation rate has not changed significantly over time. It seems likely that advances in CT technology have not benefited the youngest patients with appendicitis because they have perforated before presenting to the ED. Because many of the youngest patients are seen by medical providers before being diagnosed with appendicitis, clinicians must maintain a heightened awareness of the subtle signs and symptoms of appendicitis in this age group. Early utilization of white blood cell count and percentage of neutrophil count may be useful in an office setting to evaluate the necessity for further diagnostic imaging. Our study has the following strengths and limitations. Our study adds to the current body of literature as a result of its large sample size, high capture rate, high follow-up rate, and prospective collection of historical and physical examination findings. Clinicians should find our results helpful for evaluating a young child with acute abdominal pain. A careful history and physical examination remains the most important diagnostic tool in evaluating a child for appendicitis. Our study was limited by its retrospective nature. Although the original database was created prospectively, it was not specifically designed to address the questions of this study. The study was also limited by the fact that multiple examiners evaluated the children in the ED. Although these examiners had similar levels of training, there is likely an inherent variability in reported historical and physical examination findings. This could have introduced an element * 2007 Lippincott Williams & Wilkins

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of bias into the study, but we hope that it was limited because there were a large number of physicians (48) involved in examining patients during the course of the study. Lastly, the number of patients with appendicitis in the age-stratified subgroups was small, especially in the youngest group, where only 15 patients were diagnosed with appendicitis. Thus, age-specific conclusions must be drawn with caution.

CONCLUSIONS The key to diagnosing appendicitis in preadolescent children is conducting a careful history and physical examination. Clinicians should pay close attention to RLQ tenderness, nausea, inability to walk, or walking with limp, as these are present in the vast majority of cases. Although the presence of peritoneal signs is infrequent, when present, they substantially increase the likelihood of appendicitis, especially in the preschool age child. Vomiting, diarrhea, and fever should not be relied upon to diagnose appendicitis in preadolescent children. REFERENCES 1. Alloo J, Gerstle T, Shilyansky J, et al. Appendicitis in children less than 3 years of age: a 28-year review. Pediatr Surg Int. 2004;19(12): 777Y779. 2. Nance ML, Adamson WT, Hedrick HL. Appendicitis in the young child: a continuing diagnostic challenge. Pediatr Emerg Care. 2000; 16(3):160Y162. 3. Rothrock SG, Skeoch G, Rush JJ, et al. Clinical features of misdiagnosed appendicitis in children. Ann Emerg Med. 1991;20(1): 45Y50. 4. Gardikis S, Touloupidis S, Dimitriadis G, et al. Urological symptoms of acute appendicitis in childhood and early adolescence. Int Urol Nephrol. 2002;34(2):189Y192.

Appendicitis in Preadolescent Children

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