A 5-year-old with abdominal pain, nausea and fever may
have appendicitis or any of a number of
other problems. But how does the child's doctor decide
whether to schedule an emergency
appendectomy to surgically remove a presumably inflamed
appendix — a procedure that carries its own
risks like any surgery — or wait and observe what
could be a ticking time bomb that could rupture and
kill the patient in a matter of hours?
It's a classic physician's dilemma, but a new study
led by the
Johns
Hopkins Children's Center
may ease the pediatrician's problem solving and parents'
anxiety.
Reporting on their review of the frequency of the most
common symptoms of actual appendicitis
in children, the researchers concluded that beyond fever,
the most telltale signs are "rebound"
tenderness, pain that occurs after pressure is removed
abruptly, in the lower right part of the
abdomen; abdominal pain that starts around the belly button
and migrates down and to the right; and
an elevated white blood cell count (10,000 or more per
microliter), a marker of infection in the body.
Notably, loss of appetite, nausea and vomiting —
hallmark appendicitis symptoms in adults — were not
predictive of appendicitis in children.
"These signs don't give you an absolute diagnosis, but
they should prompt the doctor to refer
the child to a surgeon for evaluation," said study lead
author David Bundy, a pediatrician at the
Children's Center and an assistant professor in the School
of Medicine.
Appendicitis is most common in teens and young adults
in their early 20s. However, children
younger than 4 years are at the highest risk for a rupture.
Up to 80 percent of appendicitis cases in
this age group end in rupture, partly because young
children have fewer of the classic symptoms of
nausea, vomiting and pain localized in the lower right
portion of the abdomen than do teenagers and
young adults, making the diagnosis easy to miss or
delay.
In the study report, published in the July 25 issue of
the Journal of the American Medical
Association, the researchers said ultrasound and CT scan
images can be helpful but are not always
conclusive, even if they are available on an emergency
basis. And CT scans in particular expose young
children to radiation, which should be avoided if
possible.
"In a very young child, the presentation of symptoms
associated with appendicitis tends to be
different from adults, so when trying to decide between
fast-track surgery versus watchful
observation, you're often damned if you do and damned if
you don't," Bundy said. "In our analysis, we've
identified some of the more powerful telltale signs that
should help residents, general pediatricians
and ER doctors narrow down what is seldom a clear-cut
diagnosis."
The appendix is a small tube extending from the large
intestine, and infections and inflammation
of the organ can be dangerous. The only absolute way to
diagnose the condition is surgery, and each
year, appendicitis sends 77,000 American children to the
hospital. An estimated one-third of them
suffer a ruptured appendix, a life-threatening
complication, before they reach the operating room.
In their analysis of previous research, investigators
searched hundreds of studies, weeding out
weak from solid science. The 25 studies that made the final
cut examined symptoms and outcomes in
children who presented with abdominal pain and in whom
appendicitis was considered a possible
diagnosis.
Abdominal pain in children is one of the most common
and most vague symptoms, and can suggest
anything from innocent constipation to serious infections
or blockages of the intestines. Doctors
advise parents that any abdominal pain should be evaluated
for appendicitis.
"We really want parents to keep in mind that children
with appendicitis don't always show up
with the classic story that we see in adults," Bundy said.
"There isn't a perfect formula, but we think
the signs we've identified can help."
Other researchers in the study were Julie Byerly, E.
Allen Liles, Eliana Perrin, Jessica
Katznelson, all of the University of North Carolina at
Chapel Hill; and Henry Rice, Duke University
Medical Center.
The research was funded in part by the Robert Wood
Johnson Clinical Scholars Program and by
the National Institutes of Health.
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