Clinical Communiqué Volume 8 Issue 3 September 2021
Download PDF: Clinical Communiqué September 2021 Edition
In this edition
Case #1: A paediatric perforation
Case #2: Hoofbeats aren’t always horses
Expert Commentary: Children get tummy aches
In this edition we focus on paediatric appendicitis - the most common cause of acute abdomen in children. In the sense that it is such a commonplace condition, and tends to affect the young and healthy, who appear to get better quickly and go home after antibiotics or surgery, appendicitis is rarely thought of as a critical illness. Particularly in first-world health care systems, it is not a diagnosis that clinicians expect to hear about as a cause of death in a patient, let alone a child. Yet, inflammation of the appendix can result in serious consequences. Morbidity can be high in children with appendicitis – up to one-third of cases result in perforation. Abscess formation, peritonitis, and post-operative complications do occur, and the younger the child, the greater the risk. Importantly, while the mortality rate for appendicitis in children is very low, it rises significantly in cases where the appendix has ruptured. Several independent factors, including age younger than 5 years, symptom duration longer than 24 hours, hyponatremia, and leukocytosis, are all associated with an increased risk of death.
The medical profession has understood most of what it knows about appendicitis for more than a century. The condition was first described in 1886 by Dr Reginald Fitz, a medical scholar who was both a pathologist and an internist. He had painstakingly observed the diseased appendix in over 250 autopsies and pieced together the pathological and clinical sequence of an illness that had until that time been referred to as ‘iliac passion’ and incorrectly attributed to inflammation of the caecum. Dr Fitz named the condition appendicitis and announced his discovery at the initial meeting of the Association of American Physicians, to an audience that included noted medical luminaries Osler, Jacobi, Janeway and Trudeau (see Box 1).
From the very beginning, Dr Fitz had advocated early operation for acute appendicitis, and had raised concerns about complications arising from rupture of the appendix leading to generalised infection of the abdomen. One hundred and thirty-five years later, and with the advent of antibiotic therapy and improved surgical techniques, history begs the question of why children are still succumbing to seemingly preventable complications in a condition that we have long since known how to treat.
The answer lies in the challenges of differentiating between appendicitis and other surgical and medical causes of abdominal pain in children. Forming an assumption that a child with vomiting and diarrhoea has gastroenteritis might appear reasonable, but the apparent logic of this approach is rendered invalid if not paired with an alertness to respond to a subsequently unexpected clinical course. Appendicitis is primarily a clinical diagnosis, aided by a synthesis of laboratory and radiological findings. The younger the child, the more difficult the diagnosis, and the higher the rate of appendix rupture. Up to 10% of children with appendicitis are missed on initial clinical assessment.
There also remain logistical and radiotoxic reasons as to why every paediatric abdominal pain cannot or should not result in a CT scan, with plain X-ray and ultrasound options unreliable due to their potential for generating false negative results. The diagnostic difficulties are perhaps best evidenced by the more than 20 eponymous signs that have been described over many decades in attempts to assist the accurate identification of this condition.
In this edition, we describe three cases of paediatric appendicitis where delays in diagnosis and treatment tragically resulted in death. Although the cases occurred almost 10 years apart, there were similar lessons to be learned in each, demonstrating that even where there is ready access to emergency care and surgical treatment, patients are still dying. The lawyer for the family in one of these cases was quoted as saying at the time that “death from appendicitis is a ‘third world’ outcome and should not occur in [this place]”. It remains a condition where despite 21st century medicine, the diagnosis continues to elude clinicians.
The expert commentary in this edition is by Dr Susan Adams, a paediatric surgeon, who has written an excellent overview of the topic. Dr Adams offers a pragmatic and insightful approach to the assessment of children with abdominal pain. She presents key points that help to raise awareness of the most reliable red flags in diagnosing appendicitis.
Dr Fitz first drew attention to the issue of acute appendicitis and its potential to result in serious morbidity and mortality. Over a hundred years later, it is imperative that lessons are learned from cases like the ones described in this edition, so that the child with acute appendicitis is not missed again.