Inequities in the Diagnosis of Pediatric Appendicitis in Tertiary Children's Hospitals and the Consequences of Delayed Diagnosis

INTRODUCTION

Missed diagnosis (MD) of acute appendicitis is associated with increased risk of appendiceal perforation. This study aimed to investigate whether racial/ethnic disparities exist in the diagnosis of pediatric appendicitis by comparing rates of MD versus single-encounter diagnosis (SED) between racial/ethnic groups.

METHODS

Patients 0-18 y-old admitted for acute appendicitis from February 2017 to December 2021 were identified in the Pediatric Health Information System (PHIS). International Classification of Diseases, 10th Revision, Clinical Modification diagnosis codes for Emergency Department visits within 7 d prior to diagnosis were evaluated to determine whether the encounter represented MD. Generalized mixed models were used to assess the association between MD and patient characteristics. A similar model assessed independent predictors of perforation.

RESULTS

51,164 patients admitted for acute appendicitis were included; 50,239 (98.2%) had SED and 925 (1.8%) had MD. Compared to non-Hispanic White patients, patients of non-Hispanic Black (odds ratio 2.5, 95% confidence interval 2.0-3.1), Hispanic (2.1, 1.8-2.5), and other race/ethnicity (1.6, 1.2-2.1) had higher odds of MD. There was a significant interaction between race/ethnicity and imaging (P < 0.0001). Among patients with imaging, race/ethnicity was not significantly associated with MD. Among patients without imaging, there was an increase in strength of association between race/ethnicity and MD (non-Hispanic Black 3.6, 2.7-4.9; Hispanic 3.3, 2.6-4.1; other 2.0, 1.4-2.8). MD was associated with increased risk of perforation (2.5, 2.2-2.8).

CONCLUSIONS

Minority children were more likely to have MD. Future efforts should aim to mitigate the risk of MD, including implementation of algorithms to standardize the workup of abdominal pain to reduce potential consequences of implicit bias.

Delayed presentation and sub-optimal outcomes of pediatric patients with acute appendicitis during the COVID-19 pandemic

OBJECTIVE

Early presentation and prompt diagnosis of acute appendicitis are necessary to prevent progression of disease leading to complicated appendicitis. We hypothesize that patients had a delayed presentation of acute appendicitis during the COVID-19 pandemic, which affected severity of disease on presentation and outcomes.

PATIENTS AND METHODS

We conducted a retrospective review of all patients who were treated for acute appendicitis at Morgan Stanley Children's Hospital (MSCH) between March 1, 2020 and May 31, 2020 when the COVID-19 pandemic was at its peak in New York City (NYC). For comparison, we reviewed patients treated from March 1, 2019 to May 31, 2019, prior to the pandemic. Demographics and baseline patient characteristics were analyzed for potential confounding variables. Outcomes were collected and grouped into those quantifying severity of illness on presentation to our ED, type of treatment, and associated post-treatment outcomes. Fisher's Exact Test and Kruskal-Wallis Test were used for univariate analysis while cox regression with calculation of hazard ratios was used for multivariate analysis.

RESULTS

A total of 89 patients were included in this study, 41 patients were treated for appendicitis from March 1 to May 31 of 2019 (non-pandemic) and 48 were treated during the same time period in 2020 (pandemic). Duration of symptoms prior to presentation to the ED was significantly longer in patients treated in 2020, with a median of 2 days compared to 1 day (p = 0.003). Additionally, these patients were more likely to present with reported fever (52.1% vs 24.4%, p = 0.009) and had a higher heart rate on presentation with a median of 101 beats per minute (bpm) compared to 91 bpm (p = 0.040). Findings of complicated appendicitis on radiographic imaging including suspicion of perforation (41.7% vs 9.8%, p < 0.001) and intra-abdominal abscess (27.1% vs 7.3%, p = 0.025) were higher in patients presenting in 2020. Patients treated during the pandemic had higher rates of non-operative treatment (25.0% vs 7.3%, p = 0.044) requiring increased antibiotic use and image-guided percutaneous drain placement. They also had longer hospital length of stay by a median of 1 day (p = 0.001) and longer duration until symptom resolution by a median of 1 day (p = 0.004). Type of treatment was not a predictor of LOS (HR = 0.565, 95% CI = 0.357-0.894, p = 0.015) or duration until symptom resolution (HR = 0.630, 95% CI = 0.405-0.979, p = 0.040).

CONCLUSION

Patients treated for acute appendicitis at our children's hospital during the peak of the COVID-19 pandemic presented with more severe disease and experienced suboptimal outcomes compared to those who presented during the same time period in 2019.

LEVEL OF EVIDENCE

III.

Delayed presentation and sub-optimal outcomes of pediatric patients with acute appendicitis during the COVID-19 pandemic

OBJECTIVE

Early presentation and prompt diagnosis of acute appendicitis are necessary to prevent progression of disease leading to complicated appendicitis. We hypothesize that patients had a delayed presentation of acute appendicitis during the COVID-19 pandemic, which affected severity of disease on presentation and outcomes.

PATIENTS AND METHODS

We conducted a retrospective review of all patients who were treated for acute appendicitis at Morgan Stanley Children's Hospital (MSCH) between March 1, 2020 and May 31, 2020 when the COVID-19 pandemic was at its peak in New York City (NYC). For comparison, we reviewed patients treated from March 1, 2019 to May 31, 2019, prior to the pandemic. Demographics and baseline patient characteristics were analyzed for potential confounding variables. Outcomes were collected and grouped into those quantifying severity of illness on presentation to our ED, type of treatment, and associated post-treatment outcomes. Fisher's Exact Test and Kruskal-Wallis Test were used for univariate analysis while cox regression with calculation of hazard ratios was used for multivariate analysis.

RESULTS

A total of 89 patients were included in this study, 41 patients were treated for appendicitis from March 1 to May 31 of 2019 (non-pandemic) and 48 were treated during the same time period in 2020 (pandemic). Duration of symptoms prior to presentation to the ED was significantly longer in patients treated in 2020, with a median of 2 days compared to 1 day (p = 0.003). Additionally, these patients were more likely to present with reported fever (52.1% vs 24.4%, p = 0.009) and had a higher heart rate on presentation with a median of 101 beats per minute (bpm) compared to 91 bpm (p = 0.040). Findings of complicated appendicitis on radiographic imaging including suspicion of perforation (41.7% vs 9.8%, p < 0.001) and intra-abdominal abscess (27.1% vs 7.3%, p = 0.025) were higher in patients presenting in 2020. Patients treated during the pandemic had higher rates of non-operative treatment (25.0% vs 7.3%, p = 0.044) requiring increased antibiotic use and image-guided percutaneous drain placement. They also had longer hospital length of stay by a median of 1 day (p = 0.001) and longer duration until symptom resolution by a median of 1 day (p = 0.004). Type of treatment was not a predictor of LOS (HR = 0.565, 95% CI = 0.357-0.894, p = 0.015) or duration until symptom resolution (HR = 0.630, 95% CI = 0.405-0.979, p = 0.040).

CONCLUSION

Patients treated for acute appendicitis at our children's hospital during the peak of the COVID-19 pandemic presented with more severe disease and experienced suboptimal outcomes compared to those who presented during the same time period in 2019.

LEVEL OF EVIDENCE

III.

Appendiceal Perforation due to Migration of a Dental Instrument

A 40-year-old male without any past medical history accidentally swallowed a titanium dental instrument (reamer) for root canal treatment. A cathartic was prescribed at a local hospital, and the course was observed. However, since the reamer was not excreted in feces, he was referred to our hospital. After admission, CT, lower gastrointestinal endoscopy, and barium enema revealed the migration of a foreign body into the appendix and its protrusion into the intraperitoneal cavity. As an emergency operation, laparoscopic appendectomy including the foreign body was performed. The following course was favorable without postoperative complications, and he was discharged on the 2nd hospital day. We report a patient with appendiceal perforation due to a foreign body (dental instrument for root canal treatment) in the appendix.

The Role of Serum Fibrinogen Level in the Diagnosis of Acute Appendicitis

INTRODUCTION

Acute appendicitis is the most common indication for emergent surgery and affects a wide range of patients at any age group. However, inspite of the presence of various imaging modalities, biochemical markers, and scoring systems the negative appendectomy rate remain high. Serum fibrinogen, an acute inflammatory mediator is usually raised in any acute inflammatory condition and the same is expected to rise in acute appendicitis, which may be used as a new inflammatory marker in the diagnosis and more importantly in decision making of management of acute appendicitis.

AIM

To determine the relationship between the rise in the level of serum fibrinogen and acute appendicitis and its role in reducing the negative appendectomy rate.

MATERIALS AND METHODS

A total of 82 patients with clinical signs and symptoms of acute appendicitis who underwent emergency appendectomy were included in the study, the serum fibrinogen level were measured just before the operation and the sensitivity and the specificity was calculated. The final diagnosis was based on the histopathological examination.

RESULTS

In our study, the Mean±SD of serum fibrinogen in mg/dl in those patient proved to be having acute appendicitis by histopathology was 436.6±40.6 while those with normal appendix was 391.91±66.54. The area under the curve was 0.697 i.e., it has an accuracy of around 70% and this is statistically significant (p=0.018). On further sub-analysis when the cut off level of fibrinogen level was reduced to 397, it resulted in a sensitivity of 82% and specificity of 60% and if the level was further reduced to 375 it increased the sensitivity to 88% with a specificity of 55%.

CONCLUSION

In the diagnosis of acute appendicitis, use of fibrinogen blood level may be a new diagnostic acute-phase reactant with possible role in reducing negative appendectomy rate.

Perforated appendiceal diverticulitis associated with appendiceal neurofibroma in neurofibromatosis type 1

An appendiceal neurofibroma (ANF) is a rare neoplasm associated with neurofibromatosis type 1(NF-1), an inheritable neurocutaneous disorder that involves multiple systems including the intraabdominal organs. Appendiceal diverticulitis occasionally ruptures in the absence of intense abdominal pain, which can lead to serious consequences. Recent reports highlight the association between appendiceal diverticulum and appendiceal neoplasms; however, there is still little information on the association between appendiceal diverticulitis and ANF in NF-1. A 51-year-old Japanese male with NF-1 was referred to the division of surgery for mild right lower quadrant pain. It was suspected he had perforated acute appendicitis with periappendiceal abscess based on clinical manifestations and findings of computed tomography. An emergency appendectomy was conducted. The pathological examination revealed diffusely proliferated tumor cells of a neurofibroma, coexistent with multiple appendiceal diverticulums, leading to the diagnosis of perforated appendiceal diverticulitis associated with ANF. Although he developed a remnant abscess, he recovered with the conservative treatments of antibiotics and drainage. This case suggests that appendiceal diverticulitis might be a complication of appendiceal involvement of NF-1, and that it occasionally ruptures in the absence of intense abdominal pain. Clinicians should recognize that NF-1 can cause various abdominal manifestations.

Determination of surgical priorities in appendicitis based on the probability of undetected appendiceal perforation

AIM: To identify risk factors of actual appendiceal perforation when computed tomography (CT) scans suggest nonperforated appendicitis and accordingly determine surgical priority.

METHODS: We collected database of 1362 patients who underwent an appendectomy for acute appendicitis between 2006 and 2013. A single radiologist selected 1236 patients whose CT scans were suggestive of nonperforated appendicitis. Patients were divided into 2 groups: actual nonperforation group and actual perforation group according to intraoperative and pathologic features. Comparison of the 2 groups were made using binary logistic regression.

RESULTS: Of 1236 patients, 90 (7.3%) were found to have actual appendiceal perforation. Four risk factors related with actual appendiceal perforation were identified: body temperature ≥ 37.6  °C (HR = 1.912, 95%CI: 1.161-3.149; P = 0.011), out-of-hospital symptom duration ≥ 72 h (HR = 2.454, 95%CI: 1.292-4.662; P = 0.006), age ≥ 35 years (HR = 3.358, 95%CI: 1.968-5.728; P < 0.001), and appendiceal diameter on CT scan ≥ 8 mm (HR = 4.294, 95%CI: 1.034-17.832; P = 0.045). Actual appendiceal perforation group showed longer operation time, later initiation of diet, longer use of parenteral narcotics, longer hospital stay, and higher incidence of postoperative complications (P < 0.05).

CONCLUSION: We proposed here new criteria to select patients with adverse clinical outcomes after appendectomy among the patients with radiologically nonperforated appendicitis. Surgical appendectomy outcomes could be improved by determining the surgical priority according to our criteria.