Overview and diagnosis of acute appendicitis in children

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Abstract

Appendicitis represents the most common abdominal surgical emergency in the pediatric age group. Despite being a relatively common condition, the diagnosis of appendicitis in children can prove to be challenging in many cases. The goal of this article is to review the predictive utility for presenting signs and symptoms, laboratory tests, and imaging studies in the diagnostic work-up of appendicitis. Furthermore, we sought to explore the predictive utility of composite measures based on multiple sources of diagnostic information, as well as the utility of clinical pathways as a means to streamline the diagnostic process.

Introduction

Abdominal pain is one of the most common chief complaints of children seen in the emergency department, and appendicitis represents the most common abdominal surgical emergency in the pediatric population. Appendicitis occurs in approximately 70,000 children in the United States per year and accounts for approximately one-third of childhood admissions for abdominal pain and nearly 30% of the cumulative cost of all pediatric general surgical conditions combined.1, 2, 3, 4 Despite being a relatively common condition, diagnosis of appendicitis in children can prove challenging in many cases. In a retrospective cohort study of 13,328 patients, Rice-Townsend et al.5 characterized wide variation in the diagnostic approach to suspected appendicitis among children׳s hospitals, including a 3.5-fold variation in preoperative imaging and a 5-fold variation in laboratory utilization. According to data from the American College of Surgeon׳s Pediatric National Quality Improvement Program, 65% of children who underwent appendectomy for suspected appendicitis received a preoperative ultrasound and 42% underwent a computed tomography (CT) scan.6 Several factors may underlie this practice variation, including differences among hospitals with available resources and in the perceived value of different diagnostic adjuncts used individually and in combination. The goals of this article are to review the available evidence surrounding the predictive value of presenting signs and symptoms, laboratory tests and imaging studies for diagnosing appendicitis. Furthermore, we sought to explore the predictive utility of composite measures based on multiple sources of diagnostic information, as well as the utility of clinical pathways as a means to streamline the diagnostic process.

Section snippets

Clinical presentation

The classic presentation of appendicitis has been well described, and includes fever, anorexia, nausea, guarding, and migration of pain from the umbilical region to the right lower quadrant.7 However, the predictive value of these signs and symptoms for appendicitis has been found to be relatively weak in many studies. In one of the largest such studies which included 755 children presenting to the emergency department (ED) with abdominal pain, Becker et al. found that many of these “classic”

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