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 Yale-New Haven Hospital, New Haven, Connecticut, USA HealthLINK: Pediatrics
February 26, 2001

News this month
Appendicitis in children: Diagnosing a common problem

When acute appendicitis strikes, the course of treatment is straightforward—remove the infected appendix as soon as possible. What may be difficult, however, is distinguishing appendicitis from routine gastrointestinal viruses, particularly in children.

Symptoms of appendicitis. . .can sometimes be confused with common illnesses.

Where does it hurt?
Appendicitis is a common condition, occurring in about 15 percent of all people at some point in their lives, but most frequently between the ages of 10 and 30 years old. Symptoms of appendicitis—abdominal pain followed by nausea and vomiting—can sometimes be confused with common illnesses. Adding to the difficulty is that children cannot always describe their discomfort clearly or may be frightened.

Erring on the side of caution, parents often bring the child to a hospital for an assessment, which usually includes an examination by a physician followed by lab tests. If the exam and tests are negative or if symptoms subside, the patient can go home. If it’s appendicitis, the appendix is removed.

When doctors aren't sure
But what about the small number of cases that are classified as "equivocal," meaning it’s hard to tell whether it’s really appendicitis? What’s the best approach? Doctors can admit the child for a few hours for observation, which is generally enough time for appendicitis to become full-blown. Or, sometimes they can use imaging studies, such as ultrasound and CT (computerized tomography) scans, to try and see if the appendix is inflamed.

Ultrasound, CT scans found useful
A recent study conducted by emergency medicine physicians at Children’s Hospital in Boston found that using ultrasound and CT scans was beneficial in the majority of children in whom a definitive diagnosis could not be made. In the October issue of Pediatrics, lead physician Barbara Garcia Peña and colleagues reported that imaging studies were helpful in confirming diagnoses in children seen at the hospital from July through December 1998. They stated that the studies also resulted in cost savings. This team reported these same findings in the September 15 issue of JAMA (Journal of the American Medical Association).

A recent study…found that using ultrasound and CT scans was beneficial in the majority of children in whom a definitive diagnosis could not be made.

They studied 139 children and teens aged 3 to 21 years old who had signs and symptoms suggestive of appendicitis but whose clinical exam and laboratory tests were equivocal. All of these children had ultrasound examinations that led to a change in management in 13 patients. Eighteen patients were taken to surgery on the basis of a positive ultrasound and all of them had appendicitis. Thirteen children had a negative ultrasound and were either hospitalized for observation or discharged to home. Two of them subsequently had surgery for appendicitis. In 108 children, the ultrasound was not diagnostic and these children had CT scan with rectal contrast, which involves the insertion of a small amount of a radio-opaque dye into the rectum. Among these children:

  • 30 had surgery, of whom 28 had appendicitis and two had a normal appendix
  • 26 were hospitalized for observation; 25 got better and one required appendectomy later
  • 52 had a normal scan and were discharged home; none of these had appendicitis

Cost savings, patient benefit
The doctors concluded that using ultrasound and CT scan with rectal contrast was shown to be 94 percent accurate in the diagnosis of acute appendicitis. They reported that using CT scans resulted in cost savings of $565 per patient. They noted that their protocol resulted in a beneficial change in the management of that patient in 68 percent of patients seen.


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John H. Seashore, MD

Ultrasound and CT scans not necessary in the majority of cases

The use of ultrasound and CT scans has revolutionized the diagnosis of a wide variety of disorders in adults and children. However, I don’t believe these tests are necessary to diagnose the majority of cases of childhood appendicitis.

We see about 100 cases a year of acute appendicitis at Yale-New Haven Children’s Hospital. In the majority of cases—about 80 percent—the diagnosis is very clear cut to an experienced surgeon. In contrast, in the Boston study we don’t know the total number of children with appendicitis so we have no way of knowing the percentage of children with a borderline diagnosis. It is important to note that the only patients studied were those whose clinical findings were felt to be equivocal by the senior surgical resident.

“Our approach has earned us a 93% accuracy rating, which compares very favorably with the stated accuracy of 94% percent in the study.…”

CT overly aggressive?
At Yale-New Haven, if there is any doubt, we will observe the child for some time. Ultrasound can also be used, but we rarely use CT scans. In the Boston study, the use of enema contrast in 108 of 120 children presenting with abdominal pain seems overly aggressive. Our approach has earned us a 93 percent accuracy rating, which compares very favorably with the stated accuracy of 94 percent in the study and avoids having to put a child through the rigors of some of the imaging procedures.

Take home message
Probably the most important message I could deliver to parents is that appendicitis needs to be taken seriously. The real danger is from the infected appendix bursting or rupturing. The rate of rupture in children is quite high and then it’s a potentially life-threatening condition.

“…appendicitis needs to be taken seriously.”

What causes appendicitis
The appendix is a small pouch about the diameter of a pencil that hangs off the large intestine. It’s so narrow that it easily gets blocked, either if a bit of stool gets in there or if nearby lymph glands become inflamed. Secretions in the appendix can’t get out, so it builds up, bacteria multiply and the appendix becomes inflamed.

Appendicitis usually starts with pain, often in the middle of the abdomen that gradually moves to the right lower quadrant over time. Vomiting is almost always a part of it, although I’ve had some patients swear they could eat a pizza at the time of their hospital admission. Fever usually comes later, after 24 hours, and it’s rarely high unless the appendix has ruptured. So for the child who wakes up in the middle of the night burning up with fever, and then vomits, and then later develops abdominal pain, we know this is not appendicitis. Of course the best thing to do if you have any concerns is to talk to your child’s doctor.

Experience counts
The evaluation and treatment of appendicitis should be in the hands of surgeons, who have the most experience with this common problem. During an examination at the hospital, we carefully check for localized tenderness in the right lower quadrant of the abdomen, as well as spasms or tautness of the muscles in that area. If an infection is present, blood tests usually will show an elevated white blood cell count. Again, if we are not sure, our policy is to admit the child for observation, which we do for only about 10 percent of patients. Then if the child’s condition worsens, we can do surgery right away.

“I’d hate to see parents requesting ultrasounds or CT scans in every suspected case of appendicitis because it’s just not necessary.”

Prudent decision-making
Ultrasound can be useful in diagnosing this condition in selected patients, but it’s not foolproof either. By and large we will focus our attention on other measures–a careful examination of the abdomen, asking the parents about the progression of symptoms, and if necessary, taking the time to wait until symptoms get worse or go away. I’d hate to see parents requesting ultrasounds or CT scans in every suspected case of appendicitis because it’s just not necessary.

John Seashore, MD, is a pediatric surgeon at Yale-New Haven Children’s Hospital and a professor of surgery and pediatrics at the Yale University School of Medicine.
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