APPENDICITIS IN CHILDREN. A CONTINUING CLINICAL CHALLENGE Roy R. Marrero, Jr, MD, Sydney Barnwell, MD, and Eddie L. Hoover, MD Nashville, Tennessee

This article discusses the findings of a study of pre-adolescent children to determine if the mode of presentation of appendicitis had changed over the past 10 years, if the incidence of perforations decreased with age, and if diagnosis related groups (DRGs) impacted the length of hospital stay. The charts of 42 children under the age of 12 years who were discharged from two inner-city hospitals with a diagnosis of acute appendicitis from 1980 to 1989 were reviewed. There were 20 blacks and 22 whites, 26 males and 16 females with an average age of 7.31 years (range: 2 to 11 years). Over 95% of patients presented with right lower quadrant pain, 78% with guarding, 80% with a positive psoas sign, 93% with a positive Rovsing's sign, and 65% with rectal tenderness. Over 85% of patients had a history of nausea, vomiting, and anorexia. The mean duration of pain was 52.8 hours and the mean temperature was 99.60F. The mean white blood cell count was 18 176 ± 4682 for whites versus 14 615 ± 5459 for blacks. At surgery 15/42 (36%) of patients had a perforation, 11 of whom had positive wound cultures. Escherichia coli was recovered in all 11 of these patients. The average duration of pain in the perforated group was 50.9 hours, and the average age was 7 years. From the Departments of Surgery, Meharry Medical College and Metropolitan General Hospital, Nashville, Tennessee. Supported in part by the Russell and Cora Phifer Foundation and the Matthew Walker Surgical Society. Presented at the Drew-Walker Surgical Forum, 95th Annual Convention and Scientific Assembly of the National Medical Association, July 30, 1990; Las Vegas, Nevada. Requests for reprints should be addressed to Dr Eddie L. Hoover, 426 Grider St, Buffalo, NY 14215. 850

Eleven of these patients had normal bowel sounds on admission. Only 31% of the total cohort had a fecalith identified by pathology. The average postoperative length of stay was 6.5 ± 2.5 days before the initiation of DRGs and 7.5 ± 3 days afterward. (J NatI Med Assoc. 1 992;84:850-852.) Key words * acute appendicitis * lower right quadrant* DRGs * perforations Despite recent advances in diagnostic instrumentation, acute appendicitis continues to be primarily a clinical diagnosis that is frequently difficult to make in pre-adolescent children. The diagnosis should be easier to make as children reach school age because of improved communicative skills and because as children get older their signs, symptoms, and physical findings should begin to assume the more classic presentation and findings. We reviewed the charts of all children less than 12 years old discharged from two inner-city hospitals to determine if the mode of presentation had changed over the past 10 years, if the incidence of perforations decreased with age, and if diagnosis related groups (DRGs) impacted the length of hospital stay.

MATERIALS AND METHODS The charts of all children under the age of 12 who were discharged from Metropolitan General Hospital and Hubbard Hospital in Nashville, Tennessee, between 1980 and 1989 with a diagnosis of acute appendicitis were reviewed. Demographics (race, age, and sex) were recorded. A history of nausea, vomiting, anorexia, diarrhea, and location and length of pain were recorded. Physical symptoms typically associated with acute appendicitis also were noted. These consisted of fever on admission, presence or absence of bowel sounds, right lower JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 84, NO. 10

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quadrant tenderness, guarding, Rovsing's sign, psoas sign, and rectal tenderness, as well as an elevated white blood cell count (WBC). Appearance of the appendix at surgery as well as the pathological diagnosis were recorded. The results of wound cultures were noted. The number of hospital days before and after the initiation of DRGs were recorded.

RESULTS Incidence There were 26 (62%) males and 16 (38%) females. The average age was 7.31 ±2.4 years (range: 2 to 11 years; mode: 9 years). There were 19 (45.2%) blacks, and 22 (52.3%) whites, and one (.02%) Hispanic.

History A history of periumbilical pain localizing to the right lower quadrant was noted in 17 (41.5%) patients and right lower quadrant pain in 13 (31.7%). The remaining patients had atypical pain, ie, diffuse abdominal pain, epigastric pain, left lower quadrant pain, or were too young to communicate the location of the pain (26.2%). Nausea and vomiting were reported in 37 (88.1%) patients. Presence or absence of anorexia was noted in 28 of the charts. Twenty-four (85.7%) were anorexic. Diarrhea was noted in six (14%) patients. The average time between onset of pain and presentation was 41.5 hours. For nonperforated appendices, patients presented within 36.5 hours, while for perforated appendices, 50.8 hours elapsed before presentation.

Physical Findings The average temperature on admission was 99.6° ± 1.45°F. Presence or absence of bowel sounds were noted in 29 charts with 24 (82.8%) having bowel sounds. This includes 73% of patients who were perforated. Right lower quadrant abdominal tenderness was noted in 39 (95.1%) patients. Guarding was noted in 23 charts with 18 (78.3%) being positive for guarding. Presence or absence of Rovsing's and psoas signs were recorded in 15 charts. Rovsing's sign was present in 92% and psoas sign was present in 80%. Rectal tenderness was noted in 64.8%.

Laboratory Data The average WBC was 16 930 ± 4680 (range: 6.4 to 27.2 X 103). When the WBC was examined by race, it was noted that the WBC was 14 615 ± 5459 for blacks and 18 176 ± 4682 for whites. Pathologic examination revealed 15 (36%) perforaJOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 84, NO. 10

tions. Eleven (73%) had positive wound cultures. Organisms cultured were E coli (72.2%), enteric streptococcus (38.5%), Pseudomnonias aeruginosa (30.9%), and Bacteroidesfragilis (15.4%).

Complications There were three (7%) complications. There were no mortalities in this series.

DISCUSSION Acute appendicitis was first described by Fitz in 1866.1 Acute appendicitis is now the most common cause of acute abdomen in children.2-5 Operative treatment of acute appendicitis has become relatively simple if diagnosed early and the postoperative course is uncomplicated.3 The key is early diagnosis. A history of periumbilical pain localizing in the right lower quadrant associated with nausea, vomiting, and anorexia should instantly raise suspicion of acute appendicitis. This history combined with the physical findings of slight fever and right lower quadrant tenderness is the classic presentation of acute appendicitis. This diagnosis is usually based on history and physical exam alone.5 Ancillary studies have not been very diagnostic. Studies such as barium enemas have a high rate of false positives or equivocal examinations.5'6 Ultrasound studies for the diagnosis of acute appendicitis are 75% to 89% specific and 86% to 100% accurate.6 The drawbacks are that ultrasound is not 100% accurate, is not available 24 hours a day at all hospitals, and can be skewed by bowel gas.6 Computed tomography scanning can diagnose acute appendicitis but is far more accurate in diagnosing advanced cases. This and the expense of the procedure makes it prohibitive.6 Laboratory studies such as WBC count have not been of much use in differentiating acute appendicitis from other intra-abdominal problems requiring immediate surgery.3,6-8 This study was intended to determine if recent improvement in diagnostic modalities and communicative skills of children had improved our ability to make an earlier diagnosis in appendicitis. Right lower quadrant abdominal pain was present in 72% of our patients. This is the most common complaint associated with acute appendicitis.3'7'9"10 Nausea and vomiting along with anorexia were the next most common complaints. Duration of pain was consistent with the literature in that pain lasting longer than 48 hours had a higher incidence of perforation.7'8"l,)0, Presence of bowel sounds, guarding, psoas sign, Rovsing's sign, and rectal tenderness were unchanged from previous reports. 851

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The WBC count was noted to be consistent with other reports. When the WBC was evaluated based on race, black patients had a relative leukocytosis compared with whites. This has been shown in three previous studies in regard to appendicitis.'1-13 This is thought to be genetically mediated in blacks as no other cause could be identified."l The incidence of perforation in our study was not atypical. The unusual factor was that the average age of the patients who had perforations was 7 years and only one patient was younger than 4 years old. Other studies have shown an inverse relationship with perforation in regard to age with younger children having a higher rate of perforation. This is thought to be due to an inability to communicate pain symptoms.7"14 In our study it could perhaps be caused by the ignoring of symptoms by the patient and their parents for 24 to 48 hours with the expectation that they would remit. When cultured, the perforated patients grew E coli, the most common organism cultured from the peritoneum.3'15'16 These patients were all treated with an aminoglycoside along with anaerobic and grampositive antibiotic coverage. There were three complications: a pelvic abscess, a peritoneal abscess, and a superficial wound infection. The pelvic abscess was drained percutaneously and the peritoneal abscess was drained surgically. The wound infection was opened then packed. All perforations were left open to be closed by granulation or delayed closure. Finally, DRGs have come into effect to keep health-care costs down, while supposedly ensuring quality health care. Prior to DRGs, the average length of stay for patients with acute appendicitis ranged from 5.1 to 6.6 days.4"17-'9 In this study, the average length of stay was 6.5 ± 2.5 days before DRGs and 7.5 ± 3 days after DRGs. The longer length of stay after implementation of DRGs could perhaps be the result of a longer wait before presentation to the hospital, with the complications that accompany delayed presentation, ie, perforation. This has yet to be studied.

SUMMARY Our data suggest that there has been no significant change in the presentation of children with appendicitis over the past 10 years. Similarly, the ability of physicians to make the diagnosis has not been enhanced by improved technology and a presumed advancement in the communicative skills of children. The average age of children with perforation was surprising because the communicative skills of a 7-year-old should

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enhance the acumen of the clinician. Our data were consistent with previous reports of blacks having a lower leukocytosis than whites. Finally, the lack of positive correlation of length of stay with implementation of DRGs probably reflects the overall problem of inadequate access to health-care resources by indigent patients of both races. Literature Cited 1. Fitz R. Perforating ulcer of the vermiform appendix with special reference to diagnosis and treatment. Am J Med Sci. 1886;92:321. 2. Deaver JM. Acute appendicitis in children. Ann Surg. 1952; 136:243-249. 3. Holgersen L, Stanley-Brown E. Acute appendicitis with perforation. Am J Dis Child. 1971; 122:288-293. 4. Stringel G. Appendicitis in children: a systematic approach for a low incidence of complications. Am J Surg. 1987; 154:631-635. 5. Garcia K, Rosenfield N, Markowitz R, Seashore J, Touloukain R, Cichetti D. Appendicitis in children: accuracy of barium enema. Am J Dis Child. 1987; 1 41:1309-1312. 6. Hoffman J, Ramussen 0. Aids in the diagnosis of acute appendicitis. Br J Surg. 1987;76:774-779. 7. Rappaport W, Peterson M, Stanton C. Factors responsible for the high perforation rate seen in early childhood appendicitis. Am Surg. 1989;55:602-605. 8. Poole G. Appendicitis, the diagnostic challenge continues. Am Surg. 1988;54:609-612. 9. Savrin R, Clatworthy HW. Appendiceal rupture: a continuing diagnostic problem. Pediatrics. 1979;63:37-43. 10. Fujita W, Shigemoto H, Nishimoto T, Tsukiyama K, Ugati Y. Acute appendicitis: a study on 118 patients. Nippon Geka Galkkai Zasshi. 1985;86:464-469. 11. Hyman P, Westring DW. Leukocytosis in acute appendicitis: observed racial difference. JAMA. 1974;229:1630-1632. 12. Natesha R, Barnwell S, Weaver W, Hoover EL. Is there evidence for a racial difference in the misdiagnosis in patients explored for appendicitis? J Natl Med Assoc. 1989;81 :269-271. 13. Lewis F, Holcroft J, Boey J, Dunphy JE. Appendicitis in critical review of diagnosis and treatment in 1000 cases. Arch Surg. 1975; 110:677-684. 14. Joppich I. Acute abdominal pain in childhood. Langenbecks Arch Chir 1986;369:669-672. 15. Liechti R, Synder W. Acute appendicitis under age two. Am Surg. 1963;29:92-96. 16. Aronoff S, Olson M, Ganderer M, Jacobs M, Blumer J, Izant R Jr. Pseudomonas aeruginosa as a primary pathogen in children with bacterial peritonitis. J Pediatr Surg. 1987;22:861864. 17. Gilbert S, Emmens R, Putnam T. Appendicitis in children. Surg Gynecol Obstet. 1985; 1 61:261-265. 18. Harrison M, Linder D, Campbell J, Campbell T. Acute appendicitis in children: factors affecting morbidity. Am J Surg. 1984; 147:605-610. 19. Golladay ES, Sarrett J. Delayed diagnosis in pediatric appendicitis. South Med J. 1988;81 :1071-1072.

JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 84, NO. 10

Appendicitis in children: a continuing clinical challenge.

This article discusses the findings of a study of pre-adolescent children to determine if the mode of presentation of appendicitis had changed over th...
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