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Clinical Pearl: Diagnosing pediatric appendicitis at the first… : Emergency Medicine News


pediatrics, appendicitis, diagnosis


A recent study identified characteristics of pediatric patients with acute appendicitis missed in the emergency department. (JAMA Netw Open. 2021;4[8]:e2122248; The case-control study analyzed nine years of data from five centers to identify 748 children who had two ER visits in a seven-day period with the diagnosis of appendicitis made at the second visit to urgency.

A review of the cases showed that the patients probably had appendicitis at the first visit. The authors determined that more than 75% of patients with delayed diagnosis probably or possibly should have been diagnosed with appendicitis at the first emergency department visit.

Compared to children with timely diagnosis of appendicitis, children with late diagnosis were:

  • More likely to have a longer duration of abdominal pain (48-96 hours versus less than 24 hours).
  • Less likely to have pain when walking.
  • More likely to have peak abdominal pain outside the lower right quadrant.
  • Less likely to have abdominal protection.
  • More likely to have a complex chronic disease.

Children with late diagnosis had poorer outcomes, such as longer hospital stay, higher perforation rates, and were more likely to have more than two surgeries. Patients with a diagnostic delay had significantly lower rates of imaging obtained at the first ED visit.

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