Frequency and outcome of complicated appendicitis in toddlers and preschoolers

Background: Acute appendicitis is a frequent indication of emergency abdominal surgery in the pediatric population. In younger children, especially toddlers, and preschoolers, the presentation is comparatively late resulting in complicated appendicitis. This study was done to determine the frequency and outcome of complicated appendicitis in toddlers and preschoolers. Methods: This is a cross-sectional study done at the Department of Pediatric Surgery, Lady Reading Hospital Peshawar, during August 2018 and February 2019. The medical records of 144 toddlers and preschoolers who presented with acute appendicitis were reviewed for demography, clinical presentation, operative findings, and outcome. Frequency and types of complicated appendicitis were recorded. Results: The mean age of study participants was 3 years (±2.84), including 46(32%) toddlers and 98(68%) preschoolers. Overall 62% of patients were male while 38% of patients were female. Complicated appendicitis was documented in 75% of patients. The common types of complicated appendicitis were perforation of the appendix with a localized abscess in 68 patients, gangrenous appendicitis in 4 patients, generalized peritonitis in 24 patients, and mass formation in 12 patients. All patients did well after surgery, except one who succumbed to complications of leukemia. Conclusion: In our study, a great deal (75%) of toddlers and preschoolers had complicated appendicitis especially perforated appendicitis with localized peritonitis.


INTRODUCTION
Acute appendicitis is a common surgical emergency and a frequent indication for abdominal surgery in the pediatric population. [1] Up to 8% of children with abdominal pain have acute appendicitis as its etiology. [2] However, in younger children, appendicitis is considered less common, but on the other hand, this age group is also attributed to delayed presentation with multiple complications. The common complications reported in the literature are appendicitis with perforation resulting in localized or generalized peritonitis, appendicular abscess, or mass formation. [3] The rate of perforation has been reported to be as high as 82% in children younger than 5 years and almost 100% for 1-year-old. [4] This study was planned to identify the frequency of complicated appendicitis in toddlers and preschoolers and their outcomes.

METHODS
This cross-sectional study was conducted in the Department of Pediatric Surgery, Lady Reading Hospital

OPEN ACCESS
Peshawar, during August 2018 and February 2019. This study was conducted following the approval of the hospital ethical and research committee. A total of 144 toddlers and preschoolers with acute appendicitis were enrolled and evaluated for demography, clinical presentation, operative findings, and outcome. Per-operative assessment for signs of inflammation and complications like perforation, gangrene, and collection of pus in the peri-appendicular area and frank peritonitis, was performed. Postoperatively, the patients were managed with IV fluids, IV antibiotics, and analgesics. The data were analyzed with SPSS V.20. Mean (standard deviation) was computed for quantitative variables like age, duration of symptoms. Frequency and percentages were calculated for categorical variables like gender and complicated appendicitis. Complicated appendicitis was stratified with age, gender, and duration of symptoms to see effect modification. The post-stratification chi-square test was applied and a p-value <0.05 was considered as significant.

RESULTS
Of 144 patients, 46 (32%) were toddlers (1-3 years) while 98 (68%) were preschoolers (3-5 years). The mean age at presentation was 3 years (SD ± 2.84). There was a male preponderance in our study (male: 89, 62%; female: 55, 38%; M:F= 1.6:1). Twenty-six (18%) patients had a duration of symptoms ≤48 hours while 118 (82%) patients had a duration of symptoms for >48 hours. Chi square test has been applied in which P value was 0.8364 The majority of the patients in our study had abdominal pain (depicted by irritability and abdominal tenderness in toddlers) with or without localization, anorexia/reluctance to feed, increased/upper high limit of TLC, except one patient which was a known case of leukemia with pancytopenia. Ultrasound was helpful in only 38 (26%) cases, favoring acute appendicitis.
All patients underwent open appendectomy through gridiron incision, except 18 (12.5%) patients who were operated through right upper transverse laparotomy incision because their provisional diagnosis was generalized peritonitis. Complicated appendicitis was found in 108 (75%) patients. Table 1 describes the type and frequency of complicated appendicitis encountered in our study. Of these 108 complicated appendicitides, 32% were encountered in toddlers whereas 68% in preschoolers. On stratification of complicated appendicitis with respect to age of presentation ( Table 2,p-value 0.8364), duration of symptoms (Table 3, p-value 0.8024), and gender (Table 4,p-value 0.9211), the differences were not statistically significant. Among those with complicated appendicitis, 23 (21%) patients developed wound infection and 8 (7%) patients developed pelvic abscess. Patients operated through gridiron incision were discharged on the 2ndpostoperative day and the average stay for laparotomy and complications was 4 days. On follow-up, 3 patients in the complicated appendicitis cohort also developed adhesive bowel obstruction, two were managed non-operatively and one patient needed operative adhesiolysis. One patient who was known case of leukemia with pancytopenia, operated for acute appendicitis, succumbed postoperatively.

DISCUSSION
Despite the availability different scoring systems (pediatric appendicitis score) and imaging aid, the diagnosis of acute appendicitis in young children is an uphill task. [10] Most such patients present late with various complications e.g. perforation with resulting abscess formation, generalized frank peritonitis, and sepsis. The overall rate of missed diagnosis is as high as 70-100% among infants and toddlers and 19-57% in preschoolers. [3] In this study, we also encountered complicated appendicitis in 75% of cases. It is more common in males compared to females (ratio 1.4:1). [1] The same has been observed in our study (M:F= 1.6:1).
The delay in the diagnosis and management of acute appendicitis has been blamed on nonspecific presentations because of mobile cecum and the variable position of the appendix. [5]There is an overlap of symptoms with many other common pediatric illnesses like upper and lower respiratory tract infections, acute gastroenteritis, urinary tract infections, constipation, intussusception, obstructed inguinal hernia, orchitis, testicular torsion, right hip arthritis, along with the inability of the child to express and communicate properly and with a difficult abdominal examination in this age group. The most common presenting symptom in children less than 5 years old is pain, followed by nausea, vomiting, fever, anorexia, and diarrhea. The most common sign on physical examination is focal tenderness (61% of the patients) followed by guarding (55%), diffuse abdominal tenderness (39%), rebound tenderness (32%), and mass formation (6%). [6,7]  Chi square test has been applied in which P value was 0.9211 Mallick MS studied 106 patients of ≤5 years of age requiring appendectomy and reported a male preponderance in their study. Sixty-four patients (60.3%) had complicated appendicitis, 38 (35.3%) had acute appendicitis without complications, and 4 (3.7%) had normal appendix, in his study. [8] In our study, we also had a 5% rate of negative appendectomy, but the frequency of complicated appendicitis was high comparatively. Similar frequency of complicated appendicitis (70%) was reported by Singh et al. [4], but their rate of negative appendicitis was 9%. [4] In their study, perforated appendicitis was more common in patients who were younger than 5 years. More than 60% of patients presented with complicated appendicitis when the duration of symp-toms was more than 72 hours. [9] Similarly, in our study, 61% of patients with complicated appendicitis were late presenters but the difference was not statistically significant (Table 3).
Asad et al. studied the cause of complicated appendicitis and late presentation. Complicated appendicitis and late presentation in 77% patients were due to missed diagnosis by the physicians, 31% was due to missed diagnosis by the non-doctors, 23.08% was due to conservative management at various hospitals by the surgeons in periphery having no proper pediatric surgery setup, and 23.08% presented late because of self-medication at home resulting in complications and increased morbidity. [10] This aspect was not evaluated in our study.

CONCLUSION
Complicated appendicitis is more common in children under five years because of delayed diagnosis resulting in worrisome complications which can be prevented with timely diagnosis. In our study, 75% of children under five-year of age (excluding neonates and infants) developed complicated appendicitis; perforated appendicitis with localized peritonitis being the most common complication. Every abdominal pain in this age population should be evaluated in a proper pediatric surgery setup for better management.

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No clinical figure is used in this manuscript.
Authors Contribution: Author(s) declared to fulfill authorship criteria as devised by ICMJE and approved the final version. Authorship declaration form, submitted by the author(s), is available with the editorial office.