Journal List > Pediatr Infect Vaccine > v.25(1) > 1098699

Lee, Kwon, Ahn, Lee, and Kim: Acute Appendicitis in Children and Adolescents: Factors Associated with Perforation and the Causative Organism

Abstract

Purpose

This study aimed to determine which factors are related to perforated appendicitis. We also conducted a survey to identify the causative organism.

Methods

From January 2011 to December 2014, 569 pediatric patients (322 male) younger than 19 years old who underwent an appendectomy due to acute appendicitis at Hallym University Sacred Heart Hospital were enrolled. Patients' medical records were reviewed retrospectively to determine their clinical manifestations, laboratory and imaging results, and pathogens.

Results

About 127 patients (22%) had perforated appendicitis. The rate of perforated appendicitis in preschool, late childhood, and adolescent ages were 50%, 27%, and 16.8%, respectively. The risk factors of perforation were high C-reactive protein levels and the presence of appendiceal fecalith (P<0.001). Of the 24 samples of peritoneal fluid and periappendiceal pus that were collected intraoperatively, 16 were culture positive. The most common pathogen was Escherichia coli (n=10), and others were Pseudomonas aeruginosa, Streptococcus spp., and Staphylococcus spp.

Conclusions

The perforation rate of appendicitis among patients younger than 5 years old was 50%, and this decreased in proportion with age. Clinicians should be aware of the possibility of perforation when patients with appendicitis have high C-reactive protein levels or the presence of appendiceal fecalith on imaging.

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Fig. 1.
The perforation rate of acute appendicitis according to age are shown. Approximately the perforation rate was higher in younger age. The peak of perforation rate was found in 4 years age group.
piv-25-1f1.tif
Fig. 2.
Receiver operating characteristic (ROC) curves of C-reactive protein and appendiceal fecalith.
piv-25-1f2.tif
Table 1.
Clinical Characteristic and Laboratory Results of Subjects
At admission Perforation (n=442) No perforation (n=127) P-value
Age (yr) 12.3±3.7 10±4.1 <0.001
Nausea or vomiting 296 (67.0) 101 (79.5) 0.007
Diarrhea 50 (11.7) 29 (23.8) <0.001
Duration of symptom (day) 1.3 1.9 0.026
Abdominal tenderness 422 (99.1) 120 (98.4) 0.512
Abdominal rebound tenderness 357 (83.8) 112 (91.8) 0.027
White cell count (/µL) 13,363±4,685 17,575±5,172 <0.001
Absolute neutrophil count (/µL) 11,312±13,714 15,074±4,777 <0.001
Neutrophil (%) 77.5±11.9 85.3±5.9 0.006
CRP (mg/L) 21.1±35.1 91.3±64.5 <0.001
ESR (mm/hr) 13.8±18.5 35.3±19.6 <0.001
Appendiceal fecalith 101 (23) 71 (56) <0.001

Values are presented as mean±standard deviation or number (%).

Duration of symptom: time from the first abdominal pain to hospitalization.

Abbreviations: CRP, C-reactive protein; ESR, erythrocyte sedimentation rate.

Table 2.
Associated Factors of Perforation of Acute Appendicitis
Variable OR 95% CI P-value
White blood cell 1.00 1.000–1.001 0.427
Absolute neutrophil count 1.00 0.999–1.000 0.637
Neutrophil 1.02 0.954–1.09 0.559
C-reactive protein 1.02 1.014–1.025 <0.001
Duration of symptom 1.09 0.99–1.20 0.079
RLQ tenderness 1.55 0.11–22.09 0.749
RLQ rebound tenderness 2.33 0.82–6.61 0.111
Diarrhea 1.27 0.61–2.66 0.527
Appendiceal fecalith 2.51 1.43–4.40 <0.001

Abbreviations: OR, odds ratio; CI, confidence interval; RLQ, right lower quadrant.

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