It is vital to be aware of the atypical presentations of appendicitis in children. This case study demonstrates how delayed diagnosis can result in serious illness
Keywords Appendicitis, Gastroenteritis, Atypical presentation
- Atypical clinical findings can lead to difficult and delayed diagnoses.
- Routine nursing observations may reveal an elevated Paediatric Early Warning Score (PEWS) and this should prompt further clinical assessments and imaging (Bristow, 2004).
- Gastroenteritis with raised inflammatory markers should raise the suspicion of complicated appendicitis in children (Acheson and Banerjee, 2010; Chung et al, 1996).
- Paediatric surgeons should always be involved in a suspected case of appendicitis (Acheson and Banerjee, 2010).
Appendicitis is a painful inflammation and infection of the appendix. The primary cause is obstruction of the appendiceal lumen. An important cause of abdominal pain in children, appendicitis often requires emergency surgery. It is slightly more prevalent in boys than girls and usually presents between 10 and 20 years (Acheson and Banerjee, 2010).
Classic features of appendicitis include abdominal pain localising over McBurney’s point (on the right side of the abdomen between the umbilicus and the anterior superior iliac spine), fever and loss of appetite (Acheson and Banerjee, 2010; Bristow, 2004). However, the initial presentation may be atypical or mimic a different pathological process, leading to delayed diagnosis (Cappendijk and Hazebroek, 2000). Early clinical suspicion and imaging are useful in diagnosis.
Clinical presentation and initial management
A previously healthy 11 year old boy presented with a two day history of lower abdominal pain, diarrhoea and vomiting with associated loss of appetite. Initial observations showed a fever of 38.5ºC, pulse rate of 108bpm, saturations of oxygen 98% on air, blood pressure of 111/67mmHg and a central capillary refill time of two seconds. The abdomen was soft with some tenderness in the right iliac fossa but without guarding. The provisional diagnosis was gastroenteritis and the patient was managed conservatively; the need to exclude appendicitis was documented.
The boy’s blood inflammatory markers were raised with a white cell count (WCC) of 15.8/mm3 and a C-reactive protein of 224mg/L. He continued to experience diarrhoea, opening his bowels up to 10 times on the day before surgery. Senior surgeons performed serial abdominal examinations with reassuring findings and his clinical presentation was felt to be consistent with a mild gastroenteritis despite a subsequent rise in inflammatory markers. After 72 hours the patient remained pyrexial, with a mild tachycardia, and began to complain of shoulder tip pain; he was unable to tolerate oral rehydration solution. A chest X-ray at that time showed an early right basal pneumonia and IV cefuroxime and IV fluids were started.
An ultrasound scan of the abdomen was performed, which revealed an appendix abscess (Fig 1).
A laparoscopy (Fig 2) was conducted and a gangrenous perforated appendix was identified and removed. An abdominal drain was inserted for 24 hours and a strict input and output chart maintained. The patient was managed in the paediatric high dependency area.
The IV cefuroxime was continued and IV metronidazole was added to the regimen; a five day course was completed. The patient later developed breathing difficulties and a chest ultrasound scan revealed a small left pleural effusion, which was managed conservatively. Postoperative pain relief included oral morphine.
The patient was seriously ill and needed several days to recover; the total inpatient stay was 12 days. A month later, he was reported to be doing well at a clinic review and was discharged from hospital care.
This case illustrates the importance of being aware of the atypical presentations of appendicitis in children. A thorough history, repeated clinical examinations by a senior surgeon and imaging will help early diagnosis and to prevent significant morbidity.
AUTHORS Siba Prosad Paul, MBBS, DCH, is paediatric trust registrar; Natalie Paulie, DipE (Child Nursing) is paediatric nurse; Dorothy Hawes, BM, BSc, is paediatric ST1 trainee; all at St Richard’s Hospital, Chichester.
Acheson J, Banerjee J (2010). Management of suspected appendicitis in children. Archives of Disease in Childhood, Education and Practiceedition; 95: 9-13.
Bristow N (2004) Treatment and management of acute appendicitis. Nursing Times; 100: 43, 34.
Cappendijk VC, Hazebroek FWJ (2000) The impact of diagnostic delay on the course of acute appendicitis. Archives of Disease in Childhood; 83: 64-66.
Chung JL et al (1996) Diagnostic value of C-reactive protein in children with perforated appendicitis. European Journal of Pediatrics; 155: 529-531.