Acute Appendicitis in Children and Adolescents: Factors Associated with Perforation and the Causative Organism

Sol Lee; Hyuck Jin Kwon; Soo Min Ahn; Kwan Seop Lee; Kwang Nam Kim

doi:10.14776/piv.2018.25.1.1

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

Original Article

Pediatr Infect Vaccine 2018;25(1):1-7.

Published online: 20 January 2018

DOI: https://doi.org/10.14776/piv.2018.25.1.1

Acute Appendicitis in Children and Adolescents: Factors Associated with Perforation and the Causative Organism

Sol Lee¹, Hyuck Jin Kwon¹, Soo Min Ahn², Kwan Seop Lee³, Kwang Nam Kim^1,

¹Department of Pediatrics, Anyang, the Republic of Korea

²Department of Pediatric Surgery, Anyang, the Republic of Korea

³Department of Radiology, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, the Republic of Korea

책임저자: 김광남 한림대학교 의과대학 한림대학교 성심병원 소아청소년과 Tel: 031)380-3730, Fax: 031)380-3733 E-mail: kwangkim@hallym.or.kr

Received 4 August 2017 Revised 28 September 2017 Accepted 26 October 2017

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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.

Keywords: Appendicitis, Child, Adolescent

References

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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.

Fig. 2.

Receiver operating characteristic (ROC) curves of C-reactive protein and appendiceal fecalith.

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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