Delays in appendicitis diagnosis: Causes and outcomes

Not all cases of appendicitis are the same. What leads to delays in diagnosing it and are those delays preventable?

Appendicitis is the most common surgical emergency in pediatrics. When significant delays occur in diagnosis, the risk of worse outcomes, particularly a perforated appendix, (which is linked to morbidities such as abdominal abscess, small bowel obstruction, sepsis, bowel resection, longer hospital stays, and higher cost) is increased. What clinical features are linked to delays in diagnosis and how preventable are they?1

The investigators used patients who were treated at 5 pediatric emergency departments for a diagnosis of appendicitis and were aged younger than 21 years. The Pediatric Appendicitis Risk Calculator was used to measure the individual features of appendicitis and determine pretest likelihood of appendicitis. Control patients had a single visit to the emergency department that led to an appendicitis diagnosis. Case patients had 2 emergency department visits before diagnosis and a case review showed that the patient very likely had appendicitis during the first visit. The preventability of delay was described as unlikely, possible, and likely.

There were 748 children included in the study and 471 had a delayed appendicitis diagnosis. Those who had a delay in diagnosis were found to be less likely to have pain with walking (adjusted odds ratio [aOR], 0.16; 95% CI, 0.10-0.25), abdominal guarding (aOR, 0.33; 95% CI, 0.21-0.51), and maximal pain in the right lower quadrant (aOR, 0.12; 95% CI, 0.07-0.19), as well as being more likely to have a complex chronic condition (aOR, 2.34; 95% CI, 1.05-5.23). Pretest likelihood of appendicitis was 39% to 52% lower in children with a delayed versus timely diagnosis. In the subcohort of delayed diagnoses, 109 cases were likely preventable and 247 were found to be possible preventable. Cases of delayed diagnoses were found to have higher perforation rates (OR, 7.8; 95% CI, 5.5-11.3), longer hospital length of stay stay (mean difference between the groups, 2.8 days; 95% CI, 2.3-3.4 days), and undergo 2 or more surgical procedures (OR, 8.0; 95% CI, 2.0-70.4).

The investigators concluded that cases of delayed diagnosis of appendicitis often involved children who presented with milder symptoms, and the delays frequently led to worse outcomes. Additionally, many of the cases were at least possibly prevented and the fact that many of the case patients did not receive indicated imaging indicates that a push to improve rates of indicated imaging would prevent delayed diagnosis for some children.

Reference

1.Michelson K, Reeves S, Grubenhoff J, et al. Clinical features and preventability of delayed diagnosis of pediatric appendicitis. JAMA Netw Open. 2021;4(8):e2122248. doi:10.1001/jamanetworkopen.2021.22248