ABSTRACT. The mortality rate for appendicitis in children has remained relatively unchanged since the 1940s, when antibiotics were introduced in the treatment of appendiceal peritonitis. However, since this time the incidence of appen-diceal rupture has increased appreciably, presumably owing to a failure of early recognition and treatment. At Columbus Children’s Hospital, one half of all patients undergoing appendectomy for ruptured appendix in 1975 had been seen by another physician before admission, but the correct diagnosis had not been made. The history obtained by the primary physician and that given on admission were similar, yet differed from the histories given by patients whose disease had been correctly diagnosed. Findings on in-hospital physical examination of incorrectly diagnosed patients
differed from those recorded by the primary physician, but
were similar to those of patients whose disease had been
correctly diagnosed.
Since it is unlikely that the natural history of the disease has changed, the increased incidence of rupture must result either from early misinterpretation of physical findings or from greater delay by parents in responding to the child’s illness. Physicians and parents must share the responsibility equally for the increasing incidence of appendiceal rupture in children. Pediatrics 63:37-43,1979 appendicitis, barium enema, ruptured appendix.
RESULTS Incidence
Received March 10; revision accepted for publication June 20, 1978.
ADDRESS FOR REPRINTS: (R.A.S.) Department of
Surgery, West Virginia University Medical Center, Morgan-town, WV 26506.
Appendiceal
Rupture:
A Continuing
Diagnostic
Problem
Ronald A. Savrin, M.D., and H. William Clatworthy, Jr., M.D.
From the Department of Surgery, Hospital, Columbus, Ohio
Ohio State University Division of Pediatric Surgery, The Childrens
Although the quality of medical care in the
United States has been improving, management
of appendicitis in children has not kept pace. The
mortality of this common surgical disease has
remained relatively unchanged since the 1940s,
when antibiotics were introduced in the
treat-ment of ruptured appendix.’ Since then, the
morbidity of the disease appears to be increasing
because the incidence of appendicitis
compli-cated by rupture before operation is rising,
presumably because the family and the physician
have failed to recognize and treat the disease in
its early stages. A study of the various factors responsible for delay in diagnosis was made.
MATERIAL
All patients (944) undergoing appendectomy at
Columbus Children’s Hospital for appendicitis or
mptured appendix during the period from
Janu-ary 1, 1970 through December 31, 1975 were
reviewed, and the overall and age-specific
mci-dence of appendiceal rupture before operation
were determined. In 1975, of 148 children with a
preoperative diagnosis of acute appendicitis or
ruptured appendix who underwent
appendecto-my, 82 (55%) had acute appendicitis, 49 (33%) had
a ruptured appendix, and 17 (12%) had a normal
appendix (Table I).
The charts of the 49 patients who underwent
appendectomy for ruptured appendix in 1975
were reviewed, and they form the basis of this
study. The history, physical findings, laboratory
data, and operative findings were compared. Two
groups were then formed: group 1, composed of
27 patients with no previous physician contact
during their present illness; and group 2,
composed of 22 patients who had seen a physician
at least once during their illness. Six of the
patients in Group 2 (27%) had been seen by more
than one physician before the correct diagnosis
was made. Findings at the time of previous
physician contact were obtained from the
medi-cal records.
The incidence of perforation in the six-year
period was 41.8%, with a range from 35% to 56%
in single years, but no trend toward a higher or
TABLE I
148 APPENDECTOMIES, 1975
No. (%)
Acute 82 (55)
Ruptured 49 (33)
Normal 17 (12)
was a strong correlation between incidence of
rupture and age. In patients 2 years of age or
younger, incidence was 93%; in those 3 to 5 years
of age, 71%; between 6 and 10 years of age, 40%;
and in those over 10 years of age, 33%. These
figures support the fact that the diagnosis of acute appendicitis before perforation is more difficult
to make in the younger child, especially the
preschool child.
Of the 49 patients with appendiceal rupture in
1975, 22 (45%) had made a total of 33 visits earlier
during their illness to physicians who failed to
diagnose appendiceal disease. Their signs and
symptoms at the time of hospital admission and at
the time of previous physician contact were
compared.
History
Almost all the patients with ruptured
appen-dices complained of cramping abdominal pain
and vomiting (Table II). Although three fourths of
the patients who had not been seen previously by
a physician had anorexia, nausea, and right lower
quadrant pain, only one half of the patients who
were previously seen by a physician complained
of these symptoms. Diarrhea was three times
more common and dysuria five times more
common in patients whose illness had been
misdiagnosed. The history given on admission by
patients who had previously consulted a
physi-TABLE II
cian was essentially the same as that obtained by
the previous physician.
Physical Examination
On admission, all the patients had abdominal
tenderness, which included the right lower
quadrant in two thirds of the patients (Table III).
Almost all the patients had voluntary guarding,
although it was localized to the right lower
quadrant in only about one third of them.
Rebound tenderness was elicited in most patients
and was greatest in the right lower quadrant in
about one half of the patients. Bowel sounds were hypoactive or absent in about three fourths of the
patients. Approximately two thirds had rectal
tenderness, right-sided in more than half. A mass
was felt on rectal examination in only one fourth of the patients, a right lower quadrant abdominal
mass was palpable in one fifth of patients, and
rigidity was present in almost the same number.
Although physical findings in group 1 and
group 2 were similar at the time of admission,
significant differences existed in group 2 between
the physical examination on admission and that
recorded by the physician seen before admission (Table III). At the previous examination, only two thirds of the patients had abdominal tenderness, and less than one fifth had localized right lower
quadrant tenderness. Voluntary guarding was
elicited in one half of the patients, and in no
patient was this present exclusively in the right
lower quadrant. Rebound tenderness was found in
less than one half of the patients. Bowel sounds
were abnormal in one half, and only one fifth had
a rectal mass or tenderness. Interestingly, an
abdominal mass was noted in as many as one
fourth of the cases, yet none had been diagnosed as a ruptured appendix or a neoplasm. Similarly,
rigidity also was present in one fourth of the
HISTORY OF 49 PATIENTS WITH RUPTURED APPENDIX, 1975
Symptoms No Previous Previous P hysici an Contact
Physician Contact
-
AOn Admission On Before
(%) Admission Admission
(%) (%)
Cramping pain 93 91 86
Vomiting 93 91 86
Anorexia 74 50 55
Nausea 70 50 59.
Right lower 74 45 27
quadrant pain
Diarrhea 11 36 27
TABLE III
FINDINGS OF PHYSICAL EXAMINATION OF 49 PATIENTS WITH RUPTURED APPENDIX, 1975
Signs No Previous Previous Ph ysician Contact
Physician Contact
-
---On Admission On Before
(%) Admission Admission
(%) (%)
Tenderness 100 100 69
Voluntary guarding 81 82 50
Rebound tenderness 78 86 42
Rectal tenderness 66 64 20
Rectal mass 19 41 20
Rigidity 19 30 25
patients, yet none was considered to have an
“acute surgical abdomen.”
Vital Signs and Laboratory Values
The vital signs and laboratory data not only
support the diagnosis but also indicate the
sever-ity of the illness (Table IV). Heart rate on
admission was slightly higher in group 2 (average,
131/mm) than in group 1 (average, 119/mm). The
heart rate noted by the previously consulted
physician had been higher still (average, 139/
mm). The average temperature of 101.2 F that
was recorded during previous physician contact
was similar to that of 101.5 F obtained on
admission, and was almost a full degree higher
than in patients whose illness had been correctly
diagnosed. White blood cell (WBC) counts were
almost identical in group 1 (19,000/cu mm) and
group 2 (19,400/cu mm), and were similar to
those obtained during prior medical contacts
(18,000/cu mm). The WBC differential count
showed a significant shift to the left in both
groups on admission, as it had at the previous
medical contact. Roentgenograms of the
abdo-men of most patients were made on admission,
and four fifths of these showed some abnormality.
TABLE IV
VITAL SIGNS AND LABORATORY DATA FOR 49 PATIENTS WITH RUPTURED APPENDIX, 1975
No Previous Physician Contact
On Admission
Previous Physician Contact “
-On
Admission
Before
Admission
Heart rate (per mm) 1-2 years
3-4 years 5-6 years 7-8 years >9 years
170 139 124 119
140 136 133 96
150 112 124 -,i__i
Avg. (all years) Temperature (F)
1-2 years
3-4 years
5-6 years 7-8 years >9 years
119 102
102
100.3 101
131 102.4
101.4
100.6 99.5 102.2
139 102.6
103
100.6 102 101.2
Avg. (all years)
WBC count
100.7 19,100
101.5 19,400
101.2 18,000 (per cu mm)
Leukocytes (%) Roentgenogram
(% abnormal)
87 77
81 80
TABLE V TABLE VI
INITIAL DIAGNOSIS OF 49 PATIENTS WITH RUPTURED
APPENDIX, 1975
%
Gastroenteritis 26
Pharyngitis 9
Otitis media 9
Urinary tract infection 11
Fever of unknown origin 6
Abdominal pain 9
None 17
Only seven patients had had roentgenograms
prior to admission, and four of these were abnor-ma!.
Diagnosis
The diagnoses of patients in group 1 on
admis-sion were ruptured appendix, 44%; acute
appen-dicitis, 37%; and “rule out appendicitis,” 19%. In
group 2, 64% of the patients were admitted with a
diagnosis of ruptured appendix, 27% with acute
appendicitis, and 9% with “rule out
appendici-tis.” The preoperative diagnosis in patients who
had not consulted a physician previously was
ruptured appendix in 59% and acute appendicitis
in 41%. In contrast, the preoperative diagnosis in
patients who had seen another physician before
admission was ruptured appendix in 86% and
acute appendicitis in 14%.
At the time of previous physician contact,
multiple diagnoses had been made. The most
frequent (Table V) were gastroenteritis, 26%;
urinary tract infection, 1 1%; pharyngitis 9%; and
otitis media, 9%. Abdominal pain of unknown
origin was the previous diagnosis in 9%, and fever
of unknown origin in 6%. No diagnosis was listed
in 17%.
Type
of Previous ContactOf the patients in group 2, 42% had been seen
as outpatients by a private physician, 40% as
hospital inpatients, and 18% in emergency rooms
(Table VI). Of the 42% who had been seen at
Columbus Children’s Hospital, 27% had been
inpatients and 15% were seen in the emergency
room. Of all the patients seen at Columbus
Children’s Hospital, 54% were discharged
with-out operation and 46% were transferred to the
general surgical service for diagnosis and
even-tually underwent appendectomy.
Physicians consulted previously were pediatri-cians (59%), general practitioners (29%), general
surgeons (8%), and urologists (4%); 66% were
PRIOR PHYSICIAN CONTACTS OF 22 PATIENTs IN WHOM
DIAGNOSIS OF RUPTURED APPENDIX WAS MISSED, 1975
Previous Contact %
Site
Physician’s office 42
In hospital 40
Emergency room 18
Total (Columbus Children’s Hospital) 42
Type of physician
Pediatrician 59
General practitioner 29
General surgeon 8
Urologist 4
Level of training
Practicing M.D. 66
Resident (Columbus Children’s Hospital) 19 Intern (Columbus Children’s Hospital) 15
practicing physicians, 19% were residents, and
15% were interns.
Analysis
The history given by patients who had been
seen by physicians before admission was not as
suggestive of appendicitis as that given by
patients who had not previously been seen.
Although this may have made the diagnosis more
difficult, it is noteworthy that the history given on
admission was essentially the same as that given
at the time of previous physician contact. Hence,
the history, which relies on the accuracy of
patient or parent communication, cannot be cited
as a factor in failure to reach the proper diagnosis initially.
The reverse was true of the physical
examina-tion. On admission, the physical examination in
both groups was similar. However, physical
find-ings recorded by the physician consulted earlier
were much less indicative of appendicitis.
Tenderness was much less common and was
rarely located in the right lower quadrant. Guard-ing was elicited in less than half the patients and
was never predominant in the right lower
quadrant.
An explanation for this discrepancy in physical
findings may be that symptoms presented to the
primary physician could merely have reflected a
less severe disorder. Between the time of initial
evaluation and the time of hospital admission and
diagnosis, there was, presumably, a progression of
the disease. However, the average time of
previous physician contact was only 27 hours
before admission. In the course of the disease,
TABLE VII
INCIDENCE OF RUPTURE
Source
No. of
Patients
Location
of Study
Tilne
Span
Age
Group
%
Rupture
Sadrieh and Farpour’6 155 Iran 1969-1975 0-15 44
White et al.b0 206 Baltimore 1965-1970 0-14 27
Marchildon and Dudgeon’ 241 Los Angeles 1973-1975 0-17 37
Law et al.’ 50 Denver 1972-1973 0-12 36
Stone et al. 677 Atlanta 1959-1968 0-16 59
Samuels” 65 Jamaica, W.I. 1962-1967 0-10 43
Brickman and Leon4 737 New Orleans 1953-1965 0-12 38
Hudson and Chamberlains 848 Boston 1928-1939 . . . 43
Scott and Ware7 506 Boston 1939-1944 0-16 45
Longino et al. 1358 Boston 1944-1957 . . . 45
Foster and Edwards2 489 Nashville, Tenn. 1936-1955 0-13 27
Fowler’ 5414 Australia 1928-1952 . . . 28
Boles et al.2 fi37 Columbus, Ohio 1949-1958 0-16 30
Present study 944 Columbus, Ohio 1970-1975 0-18 42
probably had a ruptured appendix or at least
well-established acute appendicitis evidenced by
fever, tachycardia, and leukocytosis. Since
find-ings on physical examination depend not only on
the pathologic process but on the acumen of the
examining physician, the explanation for the
discrepancy in physical findings must be an
inadequate or incorrectly interpreted physical
examination.
Three factors support the conclusion that many
of these children received inadequate evaluation before admission. First, since these patients had a
ruptured appendix on admission (appendectomy
was performed an average of 7.3 hours after
admission), and since most had been seen by
physicians within 24 hours of admission, findings
on the earlier physical examinations should have
been nearly the same as those on admission. At
the very least, they should have been indicative of acute appendicitis or early rupture, both
requir-ing immediate hospitalization and expedient
surgical evaluation. The paucity of physical find-ings recorded by the physician who failed to make the correct diagnosis suggests that many patients
received an inadequate physical examination.
Second, the earlier physical examination showed
25% of the patients to have a rigid abdomen, 25%
an abdominal mass, and 20% a mass on rectal
examination. Despite the fact that these findings are highly suggestive, if not diagnostic, of serious
intraabdominal disease, only one fourth of the
patients were referred for surgical evaluation. Third, in 32% of the patients, diagnoses of
abdom-ma! pain of unknown origin or fever of unknown
origin had been made, or there was no diagnosis
at all. In these patients, further investigation and
evaluation would appear to have been
war-ranted.
It is interesting that the diagnosis of ruptured
appendix on admission was more common in
patients seen by another physician before
admis-sion (65%) than in patients not previously seen
(44%).
The preoperative diagnosis also was moreaccurate in patients seen before admission (85%)
than in those in whom the illness had been
improperly diagnosed (44%). Thus, on the basis of
admission history, physical examination, and
laboratory data, diagnostic accuracy was greater in cases previously misdiagnosed. Operative
find-ings showed that the two groups were
homogene-ous with respect to pathophysiologic changes. In
group 1, 59% had appendiceal abscess and 41%
had free perforation. In group 2, these figures
were 60% and 40%, respectively.
DISCUSSION
Appendicitis is a common surgical problem in
all age groups. It has been suggested’ that the
prevalence of acute appendicitis has remained
relatively unchanged during the last 40 years.
Optimal treatment requires early recognition and
prompt removal of the diseased appendix. Delay
in treatment results in appendiceal rupture and a
significant increase in morbidity. The use of
antibiotics has greatly reduced the incidence of
postoperative infectious complications2 and
mor-tality,’ yet a significant difference continues to
exist between patients with acute appendicitis
and those with ruptured appendices. Boles,
Ireton, and Clatworthy3 in 1959 reported a
complication rate of 6% in 585 cases of simple
patients with ruptured appendices. Brickman and
Leon’ in 1966 reviewed 737 children with
appen-dicitis, and found a postoperative complication
rate of 8% in patients with acute unruptured
appendicitis and of 20% in patients with a
niptured appendix. To further reduce the
morbidity of appendicitis in children, it is
neces-sary to decrease the incidence of appendiceal
rupture. This can be done only by earlier
recog-nition and prompt operative treatment.
Although the incidence of ruptured appendix
reported by major pediatric centers shows some
variance, it is generally 30% to 45% (Table VII). In a series of reports from the Children’s Hospital,
Boston,7 the incidence of appendiceal rupture in
children remained unchanged from 1928 to 1957.
Stone, Sanders, and MartinTM reported that the
incidence of perforation in children aged 16 years
or younger at Grady Memorial Hospital, Atlanta,
increased from 50% in 1959 to 83% in 1968.
Comparing an earlier report from the Children’s
Hospital, Columbus, Ohio,’ with the present
study, the incidence of ruptured appendix has
increased from 30% between 1949 and 1958 to
42% between 1970 and 1975 (P < .001).
Responsibility for earlier recognition and
prop-er management is borne by both parent and
physician. This study shows that in 55% of the
patients, the disease had progressed to perforation
before medical evaluation. Parents must be made
acutely aware of the symptoms of appendicitis
and encouraged to seek medical attention.
Our finding that 45% of patients had previously
been seen by a physician who failed to make the
diagnosis is similar to that of Stone, Sanders, and
Martin.” They reported that 39% of children with
complicated appendicitis had been seen by a
physician who failed to make the diagnosis, and,
of these, 47% were seen by a private physician
and 53% in a hospital emergency room. Our
findings are similar (Table VI). The majority of
patients were seen initially by either a general
practitioner or a pediatrician. It is the primary physician who mast be painstakingly thorough in
the evaluation of the child with abdominal pain
and must be encouraged to seek surgical
consul-tation when indicated.
Once the parent has recognized the symptoms
of appendicitis and the primary physician has
requested surgical evaluation, it becomes the
responsibility of the surgeon to make the diagno-sis and proceed with appendectomy if indicated.
Delay at this point greatly increases the risk of
appendiceal rupture. The surgeon, however,
need not accept a high incidence of negative
laparotomies in an effort to prevent perforation. White, Santillana, and Hailer’#{176}demonstrated that
a period of intensive in-hospital observation of
children in whom the diagnosis was uncertain
reduced the incidence of negative appendectomy
from 15% to 2% without a concomitant change in
the incidence of appendiceal rupture.
Plain film abdominal roentgenograms are
almost routinely obtained in patients with
signif-icant abdominal pain. Appendicolithiasis,
diag-nostic of appendiceal disease, has been described in as many as 50% of children with appendicitis.’1
Other less specific yet suggestive findings have
been es’2
Cases in which the diagnosis is uncertain
warrant further diagnostic evaluation, and the
barium enema is emerging as an important
diag-nostic modality. Barium enema examination of an
unprepared colon is a safe and simple procedure that can provide additional useful information.
Although failure of the appendix to fill is
sugges-tive, it has no diagnostic significance. Complete filling of the appendix in the absence of mucosal
abnormalities or extrinsic compression of the
cecum or terminal ileum is a reliable sign of a
normal appendix. Abnormal findings on a barium
enema may be exhibited in one of several
patterns: extrinsic compression of the tip or
medial wall of the cecum; incomplete filling of
the appendix with an abrupt cutoff of barium; or
distortion in shape or caliber of a partially filled appendix. 13
Jona, Belin, and Selke’4 performed 58 barium
enema examinations in children with suspected
appendicitis and reported that of 27 patients with
a normal study, eight had negative exploration
and, in 19, symptoms resolved. Of nine children
who had suspicious findings on barium enema,
two had progressive symptoms and acute
appen-dicitis at operation, whereas seven patients
improved under observation and were discharged
without operation. Of 20 patients who had an
abnormal barium enema and who underwent
operation, acute appendicitis was found in 18
(diagnostic accuracy 90%). Rajagopalan et al.,’5
who studied 218 adults with suspected
appendici-tis, reported that barium enema was normal in
1 1 1 patients. Exploration was performed in 15
patients and acute appendicitis was found in six;
the remaining 96 patients improved and were
discharged (5% false-negative). Of 70 patients
with abnormal studies who underwent
explora-tion, 68 had acute appendicitis (diagnostic
accu-racy 97%). The barium enema examination is
with suspected appendicitis, but should be used
by the responsible surgeon only with a careful
history and physical examination and in-hospital observation.
CONCLUSIONS
An undiminished or increasing incidence of
appendiceal rupture has been substantiated. The
decrease in diagnostic accuracy and the delay in
appropriate treatment of the child with acute
appendicitis is unacceptable. Where does the
responsibility for error lie?
We suggest that parents and physicians share
responsibility. About one half of patients with
ruptured appendices sought medical evaluation
only after perforation had occurred. For these
patients, responsibility for delay rests largely with
parents, who must be alerted to the signs and
symptoms of appendicitis and made aware of the
urgency for early medical evaluation.
The remaining children sought care before
hospital admission, most (66%) consulting a
private physician. It is impossible to know how
many had acute appendicitis and how many had a
ruptured appendix at that time, but in either case
the correct diagnosis was not made. In less than
one fourth of these children was a surgical consul-tation obtained, usually after some delay, and the rest were sent home. Surgical consultation almost always resulted in the correct diagnosis (only one
child was sent home by a surgical resident).
Certainly, responsibility for delay in these
patients lies with the examining physician.
Improved management of the child with
appendicitis begins with an informed, concerned
parent, involves a thorough, careful, and
suspi-cious primary physician willing to request early
surgical consultation, and ends with a surgeon
skilled in the observation, evaluation, and diagno-sis of intraabdominal disease.
REFERENCES
1. Fowler R: Childhood mortality from acute appendicitis, the impact of antibiotics. Med I Aust 2:1009, 1971.
2. Foster JH, Edwards WH: Acute appendicitis in infancy and childhood: A twenty year study in a general hospital. Ann Surg 146:70, 1957.
3. Boles ET, Ireton RJ, Clatworthy HW: Acute appendici-tis in children. Arch Surg 79:447, 1959.
4. Brickman ID, Leon W: Acute appendicitis in childhood.
Surgery 60:1083, 1966.
5. Hudson HW, Chamberlain JW: Acute appendicitis in childhood. I Pediatr 15:408, 1939.
6. Longino LA, Holder TM, Gross RE: Appendicitis in childhood: a study of 1,358 cases. Pediatrics 22:238, 1958.
7. Scott HW, Ware PF: Acute appendicitis in childhood. Arch Surg 50:258, 1945.
8. Stone HH, Sanders SL, Martin JD: Perforated appendi-citis in children. Surgery 69:673, 1971.
9. Mittelpunkt A, Nora PF: Current features in the treat-ment of acute appendicitis: An analysis of 1,000 consecutive cases. Surgery 60:971, 1966.
10. White JJ, Santillana M, Haller JA: Intensive in-hospital observation: a safe way to decrease unnecessary appendectomy. Am Surg 41:739, 1975.
11. Neuhauser EBD: Acute appendicitis: the x-ray examina-tion. Postgrad Med 45:64, 1969.
12. Fee HJ, Jones PC, Kadell B, et al: Radiologic diagnosis of
appendicitis. Arch Surg 1 12:742, 1977.
13. Beck RN: Barium enema examination in acute appendi-citis. JAMA 236:394, 1976.
14. Jona JZ, Belin RP, Selke AC: Barium enema as a
diagnostic aid in children with abdominal pain. Surg Gynecol Obstet 144:351, 1977.
15. Rajagopalan AE, Mason JH, Kennedy M, et al: The
value of the barium enema in the diagnosis of acute appendicitis. Arch Surg 112:531, 1977.
16. Sadrieh M, Farpour A: Acute appendicitis. Review of
970 cases. Am I Proct 26:51, 1975.
17. Marchildon MB, Dudgeon DL: Perforated appendicitis: Current experience in a children’s hospital. Ann Surg 185:84, 1977.
18. Law D, Law R, Eisemen B: The continuing challenge of
acute and perforated appendicitis. Am I Surg 131:533, 1976.
