P311 Childhood appendicitis : an analysis of current practice and the search for pragmatic indicators of disease severity in a district general hospital (DGH) setting

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Abstract

Background

Acute appendicitis is still the most common cause of surgical abdomen in children. Diagnosis in children remains a challenge as clinical presentation may not always be classical with migrating abdominal pain from periumbilical to right iliac fossa region. The risk of rupture within 24 hours of onset of symptoms is low but increases steadily thereafter. There are a number of severity scoring system available but none recommended for sole use and the lack of a national guideline in the UK compounds the problem further.

Aim

County Durham and Darlington NHS Foundation trust comprise of two moderate sized DGH located in the North of England with a paediatric catchment of around 1 00 000 children.

Aim

We present here analysis of our current practice and suggestions of a pragmatic approach to determine high risk cases requiring prompt intervention.

Subjects and Methods

A retrospective casenotes analysis of all children referred with acute abdominal pain suggestive of appendicitis over a 12 month period.

Subjects and Methods

Detailed history and physical examination were performed. Only those suspected to have appendicitis were included. Patients were grouped into Complicated (which included perforated, peri-appendicular abscess and gangrenous appendix), Uncomplicated and Normal according to histological findings.

Subjects and Methods

Information gathered were documented on a standard proforma. A pilot study of 10 cases was undertaken to refine the proforma before further data was collected.

Subjects and Methods

Data was uploaded onto an Excel spread sheet for analysis.

Results

A total of 109 cases were identified. Nine were excluded as casenotes were unavailable. Remaining 100 cases were included in the analysis.

Results

These comprised of 60 boys and 40 girls with M:F of 1.5 : 1. Age ranged between 7 to 16 years with a median age of 12.5 years old.

Results

Pre-operative investigations included blood inflammatory markers and USS. All patients had either FBC or CRP or both performed. In the complicated group inflammatory markers were significantly raised in all cases, with WCC>10×109/L and/or CRP>30 mg/L. Conversely, in the uncomplicated group, all WCC were normal and only 10% had a slight rise in CRP (10–30 mg/L). In the normal group all but one had normal investigation. This one case had raised CRP of 27 from pinworm infestation. Only 30 cases had USS performed. Of this 6 (20%) confirmed appendicitis, with only 1 case in the complicated group.

Results

Open appendicectomy was performed in 57% of cases and laparoscopically in the rest. Percentages of complicated, uncomplicated appendicitis and normal appendix removed were 28%, 60% and 12% respectively.

Results

Majority of cases had admission to surgery time of less that 24 hours. In the complicated group, 75% had surgery within 24 hours and 21% between 24–36 hours of admission. There was an isolated case that had surgical intervention at 55 hours due to comorbidities from previous intestinal surgery.

Results

Post-operative complications occurred in 12 cases; 10 in the complicated group and two in the uncomplicated cohort. Median length of stay for the whole cohort was 2.5 days but increased to 3 days in the complicated group.

Summary and Conclusion

The percentages of complicated cases, normal appendicectomies, post-operative complications and length of hospital stay in our cohort were comparable to available published data. We concluded that WCC>10×109/L, CRP>30 mg/L with a history of fever and acute abdominal pain were pragmatic indicators of complicated appendicitis which warranted prompt assessment and intervention. Our USS pick-up for appendicitis was under par compared to published data which likely reflected lack of paediatric specific expertise in a DGH setting.

Reference

1. Curtis J. Wray, Lillian S. Kao, Stefanos G Millas, Kuojen Tsao, Tien C. Acute Appendicitis: Controversies in Diagnosis and Management. Ko Current Problems in Surgery. 50 (2003):54-86.

Reference

2. Bundy DG, Byerley JS, Liles EA, Perrin EM, Katznelson J, Rice HE. Does this child have appendicitis? JAMA. 2007;298(4):438.

Reference

3. Stringer, Pledger G. Childhood appendicitis in the United Kingdom: fifty years of progress. Journal of Paediatric Surgery. July 2003. Vol 38:7:65-9.

Reference

4. Bu X, Chen J, Wan Y, Xu L.. Diagnostic Value of D-Dimer Combined with WBC Count, Neutrophil Percentage and CRP in Differentiating Between Simple and Complicated AppendicitisClin Lab 2016 Sep 1;62(9):1675-81.

Reference

5. van den Boom AL, Gorter RR, van Haard PM, Doornebosch PG, Heij HA, Dawson I. The impact of disease severity, age and surgical approach on the outcome of acute appendicitis in children. Pediatr Surg Int. 2015 Apr;31(4):339-45.

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