Content area
Full Text
A 5-year-old girl presents to the emergency department (ED) because of vomiting, abdominal pain, and fever for the past 36 hours. The pain is periumbillcal and cramping in nature, and its location has not changed since onset. The child does not have diarrhea, rash, dysuria, sore throat, or upper respiratory tract symptoms. Her temperature is 38.7°C (101.7°F), and abdominal examination reveals diffuse tenderness to deep palpation with notable rebound tenderness. There is guarding, and the pain does not decrease when the patient is distracted. The findings of the examination are otherwise normal. Plain abdominal radiographs show no abnormalities. The while blood cell (WBC) count is 16.9 / 10°/L (16,900/μL) with 0.88 (88%) neutrophils. The patient is unable to provide a urine specimen. You are concerned that this child might have acute appendicitis and question the value of the history, examination, and preliminary investigations in confirming this diagnosis.
Appendicitis is among the most serious causes of acute abdominal pain and is the most common indication for emergency abdominal surgery in children. Its incidence varies with age, sex, and clinical setting in which patients are evaluated. The prevalence of abdominal pain among pediatric ED or outpatient clinic patients is 3.0% to 5.1% for pain of less than 3 days' duration and 8.1% for pain of any duration. Appendicitis explains 1% of abdominal pain episodes, and the incidence peaks in older children and adolescents, with an estimated rate of 23.3 per 10,000 population per year in persons aged 10 to 19 years. The male-to-female ratio is 1.4:1. 1,2
Of children undergoing appendectomy for presumed appendicitis, 10% to 40% have a normal appendix and usually a nonsurgical explanation for their abdominal pain.3-10 In 15% to 40% of those undergoing appendectomy who do have appendicitis, it will have progressed to perforation3,5,7,9,10 ; this proportion is even higher (71%-100%) in children younger than 6 years.10,11 Perforation rates are higher in boys. Negative appendectomies occur more commonly in postpubertal girls--the threshold for surgery is lower in girls because of the risk of infertility associated with untreated peritonitis.3,6 Mortality has declined since the recognition of appendicitis in the 1800s; currently it is a cause of death in 0.02% to 0.8% of general populations studied.5,12 In one US...