Importance of diarrhea as a presenting symptom of appendicitis in very young children

doi:10.1016/S0002-9610(96)00417-5

The American Journal of Surgery

Volume 173, Issue 2, February 1997, Pages 80-82

https://doi.org/10.1016/S0002-9610(96)00417-5 Get rights and content

Abstract

Background

Appendicitis is an uncommon diagnosis in very young children. It is frequently complicated by delays in diagnosis, perforation, and lengthy hospital stays.

Objectives

To review our recent experience with appendicitis among children younger than 3 years old, and to identify the independent predictors of a prolonged hospital stay.

Methods

A retrospective case series review was performed on all children under age 3 who had an appendectomy for appendicitis between January 1983 and February 1994. Multiple regression analysis was used to identify the independent predictors of a prolonged hospital stay.

Results

Sixty-three children were identified. Mean age was 2.2 years (range 11 to 35 months). The mean delay from onset of symptoms to presentation was 4.3 days. Fifty-seven percent were initially misdiagnosed. Diarrhea was reported in 33%. Perforation and/or gangrene were found in 84%. Perforation and/or gangrene at laparotomy and a history of diarrhea at presentation were independent predictors of a prolonged hospital stay.

Conclusions

Appendicitis in children under 3 years old is characterized by delays in diagnosis and perforation. A history of diarrhea is an important factor that confuses the diagnosis, prolongs the observation period, and delays appropriate therapy.

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Cited by (93)

Impact of the coronavirus disease 2019 (COVID-19) pandemic on the presentation of paediatric acute appendicitis: an observational study
2022, Clinical Radiology
To determine whether there were differences in the clinical presentation of patients imaged to evaluate for acute appendicitis in 2020 compared to 2019 with the hope that this information might better identify patients who should undergo imaging work-up and those who should not.
This retrospective observational study included patients <18 years who were evaluated for appendicitis between 1 March and 31 May 2019 and 2020. A total of 465 patients were stratified by final diagnosis (appendicitis versus not appendicitis) and compared based on presenting symptoms, physical examination findings, vital signs, and laboratory test results.
Symptoms and physical examination findings that were significant in the positive cohort in both years included right lower quadrant pain, pain with movement, migration of pain, right lower quadrant tenderness, and peritoneal findings. Reporting upper respiratory symptoms was an independent predictor of negative results among all patients and in 2019. Both negative cohorts were more likely to have negative physical examinations. Anorexia and nausea/vomiting were more likely among positive cases in 2019 whereas diarrhoea was more likely among positive cases in 2020.
The COVID-19 pandemic did not significantly change the presenting features of acute appendicitis. The results of the present study emphasise the importance of the physical examination. The ambiguity of symptoms that mimic gastroenteritis justifies imaging in these patients.
Delayed presentation and sub-optimal outcomes of pediatric patients with acute appendicitis during the COVID-19 pandemic
2021, Journal of Pediatric Surgery
Citation Excerpt :
Additionally, we noted increased use of antibiotics, longer LOS during initial admission, more frequent treatment failure or complications and longer duration until symptom resolution for patients treated during the pandemic. Our findings are consistent with current literature suggesting that delayed diagnosis is associated with higher incidence of complications [11,16–19]. As noted by Pham et al., pediatric patients with symptoms greater than 24 h were over five times more likely to have complicated appendicitis when compared to those with symptoms for 24 h or less [22].
Early presentation and prompt diagnosis of acute appendicitis are necessary to prevent progression of disease leading to complicated appendicitis. We hypothesize that patients had a delayed presentation of acute appendicitis during the COVID-19 pandemic, which affected severity of disease on presentation and outcomes.
We conducted a retrospective review of all patients who were treated for acute appendicitis at Morgan Stanley Children's Hospital (MSCH) between March 1, 2020 and May 31, 2020 when the COVID-19 pandemic was at its peak in New York City (NYC). For comparison, we reviewed patients treated from March 1, 2019 to May 31, 2019, prior to the pandemic. Demographics and baseline patient characteristics were analyzed for potential confounding variables. Outcomes were collected and grouped into those quantifying severity of illness on presentation to our ED, type of treatment, and associated post-treatment outcomes. Fisher's Exact Test and Kruskal-Wallis Test were used for univariate analysis while cox regression with calculation of hazard ratios was used for multivariate analysis.
A total of 89 patients were included in this study, 41 patients were treated for appendicitis from March 1 to May 31 of 2019 (non-pandemic) and 48 were treated during the same time period in 2020 (pandemic). Duration of symptoms prior to presentation to the ED was significantly longer in patients treated in 2020, with a median of 2 days compared to 1 day (p = 0.003). Additionally, these patients were more likely to present with reported fever (52.1% vs 24.4%, p = 0.009) and had a higher heart rate on presentation with a median of 101 beats per minute (bpm) compared to 91 bpm (p = 0.040). Findings of complicated appendicitis on radiographic imaging including suspicion of perforation (41.7% vs 9.8%, p < 0.001) and intra-abdominal abscess (27.1% vs 7.3%, p = 0.025) were higher in patients presenting in 2020. Patients treated during the pandemic had higher rates of non-operative treatment (25.0% vs 7.3%, p = 0.044) requiring increased antibiotic use and image-guided percutaneous drain placement. They also had longer hospital length of stay by a median of 1 day (p = 0.001) and longer duration until symptom resolution by a median of 1 day (p = 0.004). Type of treatment was not a predictor of LOS (HR = 0.565, 95% CI = 0.357–0.894, p = 0.015) or duration until symptom resolution (HR = 0.630, 95% CI = 0.405–0.979, p = 0.040).
Patients treated for acute appendicitis at our children's hospital during the peak of the COVID-19 pandemic presented with more severe disease and experienced suboptimal outcomes compared to those who presented during the same time period in 2019.
III
Appendicitis
2018, Principles and Practice of Pediatric Infectious Diseases
Appendicitis in the Infant Population: A Case Report and Review of a Four-Month Old with Appendicitis
2016, Journal of Emergency Medicine
Citation Excerpt :
Perforation was reported in 84% of this subset. Thus, irritability, grunting respirations, and diarrhea may be present in younger patients, making appendicitis difficult to differentiate from a primary respiratory disease process, intussusception, or gastroenteritis; which are more common diagnoses in this age group (1,4–9). Physical examination findings vary with age, with irritability sometimes the only sign in neonates.
Appendicitis is uncommon in children <6 months old, with few observational studies reporting cases of children younger than 5 years old with the diagnosis. The classic periumbilical pain that migrates to the right lower quadrant, followed by the onset of fever and vomiting, is present in approximately 40% of pediatric patients under 12 years of age with appendicitis.
A 4-month-old girl presented to the Emergency Department (ED) with acute onset of grunting, pallor, fussiness, emesis, and diarrhea. The patient was initially afebrile, tachycardic, and tachypneic with a soft, nondistended, nontender abdomen and active bowel sounds. The patient became febrile, with a maximum temperature of 39.3°C (102.7°F), and remained tachycardic despite receiving fluids and antipyretics. Laboratory studies were notable for mild dehydration and sterile pyuria. Chest x-ray study was negative for infectious etiologies. Initial abdominal ultrasound found no clear etiology of the patient's symptoms. The patient was admitted to inpatient pediatrics for dehydration, fever, and presumed pyelonephritis. Twenty-four hours later the patient's abdomen became distended and diffusely tender to palpation, with obstipation and increasing episodes of emesis. Abdominal x-ray study demonstrated mild gaseous distension of multiple bowel loops with repeat abdominal ultrasound notable for a focal 8-mm, noncompressible hyperemic structure in the right lower quadrant. The patient was taken to the operating room for a laparoscopic appendectomy.
Appendicitis is a potentially life-threatening condition. In the infant population it frequently presents without the features typically seen in older children.
Appendicitis in preschool aged children: Regression analysis of factors associated with perforation outcome
2015, Journal of Pediatric Surgery
Apply multivariate regression analysis to determine the significance of clinical variables for perforation outcome of a large series of preschool aged children with appendicitis.
Retrospective case review of 180 consecutive children < 5 years of age diagnosed with appendicitis during an 8-year period.
This age group accounted for only 9% of all cases of pediatric appendicitis at our institution during the study period. Perforation rate was inversely proportional to patient age, occurring in 100% aged < 1 year, 91% ages 1–2 years, 76% ages 2–3 years, 73% ages 3–4 years, and 57% ages 4–5 years. Risk for perforation increased proportionately with duration of symptoms, ranging from 48% when < 1 day vs 84% when > 1 day; and 93% when > 2 days. One-quarter with perforation had a prior recent medical evaluation with an alternative diagnosis rendered preappendicitis diagnosis. The mean duration of hospitalization was four times longer in those with perforation [8 days] vs no perforation [2 days]. Univariate analysis showed each of the following factors was significantly associated with perforation outcome: younger patient age, female gender, prior medical visit < 48 hours of appendicitis diagnosis, symptom duration, presence of fever, and presence of appendicolith. Multivariate logistic regression combining all significant univariate predictors showed only duration of symptoms and presence of appendicolith were significantly associated with perforation outcome; receiver-operating characteristic curves are generated to evaluate the predictive accuracy of these two factors, both individually and when combined.
Although relatively uncommon in this age group, appendicitis is frequently associated with delayed diagnosis and perforation outcome. Risk for perforation is directly proportional to increasing duration of symptoms. Clinicians must maintain a high index of suspicion for this condition in these younger children, as early diagnosis is essential to maximizing outcome.
The Clinical, Laboratory and Imaging Tests in Diagnosing Acute Appendicitis in Children: A Retrospective Study in a Tertiary University Hospital in Tehran, Iran
2023, Journal of Iranian Medical Council

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Importance of diarrhea as a presenting symptom of appendicitis in very young children

Abstract

Background

Objectives

Methods

Results

Conclusions

Am J Surg.

Am J Surg.

Diagnosis of appendicitis in infancy: The value of abdominal radiographs

Am J Dis Child.

Appendicitis during the first two years of life

Arch Surg.