The impact of diagnostic delay on the course of acute appendicitis

V C Cappendijk; F W J Hazebroek

doi:10.1136/adc.83.1.64

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The impact of diagnostic delay on the course of acute appendicitis

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Impact of diagnostic delay on acute appendicitis
Peter F Jones
Published on: 9 January 2022
Re: The impact of diagnostic delay on the course of acute appendicitis
Stephen K Dotse
Published on: 9 January 2022
Re: Factors delaying diagnosis of appendicitis in children
VC Cappendijk
Published on: 9 January 2022
Factors delaying diagnosis of appendicitis in children
Yim Yee Chan
Published on: 9 January 2022

Published on: 9 January 2022
Impact of diagnostic delay on acute appendicitis
- Peter F Jones, Emeritus Clinical Professor of Surgery
Dear Editor
Cappendijk and Hazebroek (Arch Dis Child 2000;83:64-6) conclude from their data that "the major factor in delay is suspected gastroenteritis". Other studies have not given this factor such prominence and the study population suggests that the Sophia Hospital was acting as a referral centre: 32 of 78 children whose admission was delayed for 48 hours had been seen first by a paediatrician, which may i...
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Dear Editor
Cappendijk and Hazebroek (Arch Dis Child 2000;83:64-6) conclude from their data that "the major factor in delay is suspected gastroenteritis". Other studies have not given this factor such prominence and the study population suggests that the Sophia Hospital was acting as a referral centre: 32 of 78 children whose admission was delayed for 48 hours had been seen first by a paediatrician, which may increase the numbers with suspected gastroenteritis.
In seeking the chief causes of delayed diagnosis it is helpful to study all children referred to a district hospital from its catchment area. Jackson in Newcastle found that parental delay over consulting the family doctor was important and then, in nearly one-third of 311 home visits, the practitioner did not decide until a second visit that admission to hospital for ?acute appendicitis was needed.[1] Jackson, a paediatrician, did not identify gastroenteritis as a factor. Other work confirms these findings.[2]
In Aberdeen over 300 children are admitted annually from our region with acute abdominal pain, and have been studied prospectively since 1965.[3, 4] This soon revealed that about one-third had acute appendicitis, one-third progressively settled without treatment (acute non-specific abdominal pain, or NSAP) and others had medical and surgical conditions. Among one year's admissions we found that 20 (18%) of 114 children with proven acute appendicitis complained of diarrhoea compared with 9% of 119 children with NSAP. Of the 20, 15 had rectal tenderness and proved to have pelvic appendicitis or peritonitis: we emphasised the importance of identifying, among the many children with gastroenteritis seen by family doctors, the few who also complain of abdominal pain, who require careful abdominal and rectal examination.[3] The practice of "Active Observation" encourages this.[4]
Occasionally delay in diagnosis of appendicitis is seen by the surgeon on a call to the isolation ward, where a child has been mistakenly sent in with suspected gastroenteritis, but this has not, over the years, been a major problem.
Peter F Jones
Emeritus Clinical Professor of Surgery
University of Aberdeen, UK
References
(1) Jackson RH. Parents, family doctors and acute appendicitis in childhood. BMJ 1963;ii:277- 81.
(2) Moss JG, Barrie JL, Gunn AA. Delay in surgery for acute appendicitis. J R Coll Surg Edin 1985;30:290-3.
(3) Winsey HS, Jones PF. Acute abdominal pain in childhood: analysis of a year's admissions. BMJ 1967;i:653-5.
(4) Driver CP, Youngson GG. Acute abdominal pain in children: a 25-year comparison. Health Bulletin 1995;53:167-72.
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Conflict of Interest:
None declared.
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Published on: 9 January 2022
Re: The impact of diagnostic delay on the course of acute appendicitis
- Stephen K Dotse, Paediatrician
Dear Editor
The article from the Netherlands by Cappendijk and Hazebroek[1] has again confirmed what is already known in clinical practice. A recent paper from the Leicester Royal infirmary[2] is almost identical.
As the authors pointed out, the factors determining the diagnostic delay are numerous and often cannot be influenced. However, I agree with their statement that “in a child with abdominal pai...
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Dear Editor
The article from the Netherlands by Cappendijk and Hazebroek[1] has again confirmed what is already known in clinical practice. A recent paper from the Leicester Royal infirmary[2] is almost identical.
As the authors pointed out, the factors determining the diagnostic delay are numerous and often cannot be influenced. However, I agree with their statement that “in a child with abdominal pain which do not settle quickly, appendicitis should be excluded by early and if necessary repeated surgical consultations”.[1]
The vermiform appendix varies from 2 cm to 24 cm in length, the average being about 9 cm. It is longer in the child than in the adult. The position of the appendix shows a high variation in children. [3, 4] This variation in the location of the appendix in the abdomen explains the variation of symptoms seen with acute appendicitis. If the appendix is retrocaecal or located in the posterior portion of the abdomen, localisation of the pain and tenderness on examination occur late if at all. If the appendix is posterior in the pelvis, the pain may localise only to the lower abdomen. And tenderness to palpation is poorly localised. The diarrhoea of appendicitis is most common in patients with a low-lying appendix in proximity to the colon and rectum.[5]
We recently saw a 9-year-old boy presenting with maximum tenderness in the left iliac fossa. There was a 31-hour history of generalised abdominal pain followed by vomiting. He was referred to the surgeon with the diagnosis of generalised peritonitis. Examination under anaesthesia revealed a mass in the left iliac fossa. Laparotomy confirmed a generalised peritonitis resulting from a left iliac fossa abscess. This was from a ruptured appendix, the tip of which was in the left iliac fossa.
References
(1) Cappendijk VC, Hazebroek FWJ. The impact of diagnostic delay on the course of acute appendicitis. Arch Dis Child 2000;83:64-6
(2) Williams N, Bello M. Perforation rate relates to delayed presentation in childhood acute appendicitis. J R Coll Surg Edin 1998;43: 101-2
(3) Bakheit MA, Warille AA. Anomalies of the vermiform appendix and prevalence of acute appendicitis in Khartoum. East Afr Med J 1999;76:338-40
(4) Johnston TB, Whillis J. Gray’s Anatomy 1942; 28th Edition, Longmans, Green and Co.
(5) Shandling B, Fallis JC. Acute appendicitis. In Nelson’s Textbook of Paediatrics. 1992; 14th Edition, Behrman R. W.B. Saunders Company
Dr Stephen Kwame Dotse
115 Nab Wood Drive
Shipley, West Yorkshire BD18 4AP, UK
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Conflict of Interest:
None declared.
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Published on: 9 January 2022
Re: Factors delaying diagnosis of appendicitis in children
- VC Cappendijk, MD
Dear Editor
In reply to the comments by Yim Yee Chan and R Lakshman in which they ask if all patients truely suffered from appendicitis in our study group. The answer is that histopathological investigation confirmed the diagnosis appendicitis in all cases.
Yours sincerely,
VC Cappendijk, MD and FWJ Hazebroek, MD, PhD
Department of Paediatric Surgery, Sophia Children's Hospital...
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Dear Editor
In reply to the comments by Yim Yee Chan and R Lakshman in which they ask if all patients truely suffered from appendicitis in our study group. The answer is that histopathological investigation confirmed the diagnosis appendicitis in all cases.
Yours sincerely,
VC Cappendijk, MD and FWJ Hazebroek, MD, PhD
Department of Paediatric Surgery, Sophia Children's Hospital
University Hospital Rotterdam
The Netherlands
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Conflict of Interest:
None declared.
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Published on: 9 January 2022
Factors delaying diagnosis of appendicitis in children
- Yim Yee Chan, Research Fellows
- Other Contributors:
  R Lakshman
Dear Editor
The paper by Cappendijk and Hazebroek[1] successfully demonstrates the problems with diagnosis of appendicitis in the young child.
It makes the important point that diarrhoea may be a feature of appendicitis and lead to misdiagnosis. In addition, children can have coexisting pathologies leading to delayed diagnosis. We have seen a cystic fibrosis child with DIOS (distal intestinal obstruction...
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Dear Editor
The paper by Cappendijk and Hazebroek[1] successfully demonstrates the problems with diagnosis of appendicitis in the young child.
It makes the important point that diarrhoea may be a feature of appendicitis and lead to misdiagnosis. In addition, children can have coexisting pathologies leading to delayed diagnosis. We have seen a cystic fibrosis child with DIOS (distal intestinal obstruction syndrome) and appendicitis. Urinary tract infection and appendicitis can also occur together.
Children with communication problems and learning difficulties are another high risk group for delay in diagnosis.
The differential diagnosis of appendicitis is large[2] and a child who presented with abdominal pain and subsequently had appendectomy need not necessarily have suffered from appendicitis. We would be interested to know whether the histopathological results were in agreement with clinical diagnosis.
References
1. Cappendijk VC, Hazebroek FWJ. The impact of diagnostic delay on the course of acute appendicitis. Arch Dis Child 2000;83:64-6
2. Hutson JM, Woodward AA and Beasley SW. Jones' Clinical Paediatric Surgery - Diagnosis and management. Blackwell Science Asia publications. Fifth Edition. 1999;Chapter 20:page 142.
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Conflict of Interest:
None declared.
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