Pediatric Complicated Appendicitis

Abstract

The objective of this study is to assess the frequency and the diagnostic features of complicated appendicitis in children and to search for factors that can predict the type of complication that may occur. We conducted a descriptive and analytical retrospective study over an 8-year period from July 1, 2010 to June 31, 2018, including children diagnosed and treated for the following complications. The data were collected at the pediatric surgery department of the Albert Royer Children’s Hospital of Dakar. We collected 143 cases, representing 67.77% of all appendicular pathology. Encountered complications were 47.6% of abscesses, 42.6% of peritonitis, and 9.8% of appendicular mass. Appendicular syndrome was reported in 40.1% of cases, peritoneal irritation syndrome in 27.7% of cases, and occlusive syndrome in 6.2% of cases. Abdominal ultrasonography and plain X-ray allowed the diagnosis to be made in the majority of the cases. The analytical study showed that the clinical presentation and the white cell count can indicate the type of complication, unlike age and the duration of symptoms. In our practice, appendicular pathology often presents itself in complicated form. The clinical picture and the blood investigations’ results can point to the type of complication.

1. Introduction

Appendicular disease is one of the most common emergencies in visceral, pediatric surgery. It is a common disease, well known and falsely reputed to be benign. Appendicitis can lead to complications. The wide variation of symptoms contributes to delayed diagnosis and then to the occurrence of complications. The latter happens, such as appendicular abscess, appendicular mass, or peritonitis. These complicated appendicitis represent 30 to 70% of all appendicitis [1, 2]. They remain of great interest in our regions, where they are the most common presentation of appendicitis, with a high rate of morbidity [3, 4, 5]. Despite improvement of surgical techniques and implementation of medical management of pediatric complicated appendicitis, morbidity still reaches 5 to 14% [6]. We aimed to determine the frequency of complicated appendicitis, their diagnostic aspects, and the existence or not of predictors of complications type.

2. Patients and method

We conducted a retrospective study, descriptive and analytic, over eight years, from July 2010 to June 2018. We included patients aged from zero to 15 years diagnosed with appendicular mass, abscess, or peritonitis and managed in our pediatric surgery department, at Albert Royer National Children’s Hospital Center, in Dakar. We collected 211 files of appendicular diseases. There were 89 boys and 60 girls. The mean age was 10.2 years, ranging from two to 15 years. In the descriptive part, we studied the frequency of complicated appendicitis, the complication type, and the positive diagnosis elements. In the analytic study, we tried to determine the existence of predictors of the kind of complication. Therefore, patients were subdivided into two groups according to age, with the first having patients aged five years and the second ranging from six to 15 years. We analyzed the following parameters with the type of complication: age, duration of symptoms, clinical presentation, and rate of white blood cells. The statistical method used was Fischer’s exact test, with significance settled at p less than 0.05.

3. Results

3.1 Descriptive study

During the eight years of our study, we collected 143 cases of complicated appendicitis among the 211 cases of appendicitis, i.e., 67.77% of complicated forms. Among the 143 children with a complication, 68 had an abscess (47.6%), 61 a peritonitis (42.6%), and 14 had an appendicular mass (9.8%). A third of patients (37.5%) received at least one antibiotic before admission. We noted that 84.6% of them were referred from other medical institutions. Clinical presentations were grouped in appendicular syndrome (pain and tenderness in the right iliaca fossa, and cutaneous hyperesthesia), found in 57 patients, i.e., 40.1% of cases, peritoneal irritation syndrome (diffuse abdominal pain, generalized abdominal tenderness or contracture, and panful umbilical palpation) in 40 patients, i.e., 27.7% of cases, and ileus in nine patients, i.e., 6.2% of cases.

The mean white blood cell count for biology was 14,012 elements/mm^3, and the mean CRP was 144 mg/l. Bacteriological examination identified a pathogen in 37 patients, and Escherichia coli was found in 62.1% of cases. Abdominal ultrasound allowed the diagnosis and determined the type of complication in 55.5% of cases. In 70% of children, a plain x-ray was realized; in 5.6% of patients, we needed an abdominal CT scan. A fourth of patients were managed using laparoscopy, as open surgery was used in the majority of case. The mean duration to surgery was 24 hours (6 – 30 hours).

Empiric antibiotics was made of three antibiotics, started from admission and continued until the postoperative period. Most used antibiotics were Matronidazole and Gentamicin each in 74.1% of cases, ampicillin in 66.1%, amoxicillin plus clavulanic acid in 8% of cases, third generation cephalosporins in 2.7% of cases and fluoroquinolones in 0.9%. A specific antibiotherapy was initiated in all patients for whom identified bacteria was resistant to molecules of empiric antibiotherapy. Hence, Ceftriaxone and Cefotaxime were respectively used in 3.6 and 2.7% of patients. Ciprofloxacin was used in 1.8% of cases, Ticarcillin and Imipenem were separately used each on a single patient, i.e. 0.9% of cases.

Postoperative complications occurred in 38% of patients, mainly represented by abdominal wall surgical site infection. Death occurred in 2.4% of cases.

3.2 Analytic study

3.2.1 Age/type of complication

Table 1 shows the repartition of type of complication according to patients’ age. Statistical analysis of these variables did not find a significant difference between age and type of complication (p = 0,348).

Age ranges (in years)	Diagnosis			Total
	Appendicular Abscess (%)	Appendicular peritonitis (%)	Appendicular mass (%)
[0 – 5]	2 (40.0)	3 (60)	0 (0.0)	5 (100)
[6, 7, 8, 9, 10]	25 (45.5)	23 (41.8)	7 (12.7)	55 (100)
[11, 12, 13, 14, 15]	26 (50.0)	22 (42.3)	4 (7.7)	52 (100)
Total	53 (47.3)	48 (42.9)	11 (9.8)	112 (100)

Table 1.

Type of complication according to age.

3.3 Symptoms duration/type of complication

Symptoms duration was given in 122 patients with a mean of 4 days. It was less than 2 days in 13 patients (10.7%). In 49 patients (40.2%), it was between 2 and 5 days; in 60 patients (49.2%), it was more than 5 days. Statistical analysis between symptoms duration and type of complication did not find any significant difference (p = 0.71).

3.4 Clinical presentation/type of complication

Clinical presentation and type of complication analysis showed that appendicular syndrome was found in patients with appendicular abscesses. However, peritoneal irritation syndrome and ileus were essentially noted in patients with peritonitis from perforated appendicitis. Then, there was a significant link between clinical presentation and type of complication, p = 0.003.

3.5 White blood cells count/type of complication

In 9 patients, i.e. 6.3%, the WBC were less than 10,000 elements/mm³, in 12 patients, i.e. 8.5%, it was between 10,000 and 12,000, in 24 patients, i.e. 17%, it was between 12,000 and 15,000, and in 94 patients, i.e. 66%, it was at least 15,000 elements/mm. In cases of peritonitis or appendicular abscess, 75, and 72%, respectively, as shown in Table 2. Analysis of white blood cell count and type of complication showed a significant link (p = 0.002).

Symptoms duration (in days)	Diagnosis			Total
	Appendicular Abscess (%)	Appendicular peritonitis (%)	Appendicular mass (%)
< 2	6 (60,0)	3 (30)	1 (10.0)	10 (100)
2 - 5	18 (47.4)	20 (52.6)	0 (0.0)	38 (100)
> 5	17 (36.2)	22 (46.8)	8 (17.0)	47 (100)
Total	41 (43.2)	45 (47.4)	9 (9.5)	112 (100)

Table 2.

Type of complication according to symptoms duration.

4. Discussion

Complicated appendicitis represents 30 to 60% of all pediatric appendicitis, as stated by many authors [7, 8, 9]. For some, it represents an entirely different entity, not necessarily from uncomplicated appendicitis [7, 10, 11]. Its frequency in our series was 67.77%, frankly more than data reported in the literature. This high frequency of complicated appendicitis with delayed presentation could be explained by delayed diagnosis due to auto-medication, lack of qualified health workers in peripheral medical institutions, and the abusive use of antibiotics. A third of our patients already received antibiotics prior to diagnosis of appendicitis.

The symptoms duration was between 2 and 5 in half of the cases. After analysis, this does not impact the type of complication (p = 0.71). In the case of complicated appendicitis, peritoneal irritation syndrome and ileus favored the presence of peritonitis, while appendicular syndrome was oriented towards appendicular abscess or mass (p = 0.003). These orientation elements could allow the creation of diagnostic guidelines. Such guidelines, like acute appendicitis, aim to ease the diagnosis and implement better therapeutic strategies for each case [12]. If a detailed clinical examination can diagnose uncomplicated appendicitis, the diagnosis of type of complication is more difficult in the case of a complicated one. However, it is crucial for adapted management. Biological data are more objective and reproducible [13, 14], but their value should be correlated to the clinical presentation [15]. So, some factors, such as fibrinogen, predict perforated appendicitis [16]. Most of our patients had a white blood cell count of at least 15,000 elements/mm. The statistical analysis showed a significant link between white blood cell count and the type of complication. In our series, a link between CRP and type of complication was not investigated to avoid bias since only 42% of patients had this dosage realized before administering antibiotics. Management of appendicular disease benefited from improvement of minimally invasive surgery. However, in our context, open surgery is still mainly practiced. The use of laparoscopy for management of these diseases is difficult due to underequipement and organizational reasons for emergency management. Its use would allow decrease of surgical site infection. High mortality in our series, for other African studies may be linked to delayed diagnosis, automedication, and low socioeconomic level.

5. Limitations

Limitations of our studies are due to its retrospective nature: inflammatory investigations were not done in all patient before antibiotics were started. Patients referred to other hospitals for not working operating room were not included in our study. A third of patients received antibiotics prior to admission, as the remaining received their first dose on admission day.

6. Conclusion

Complicated appendicitis is a spectrum of appendicular pathology which is still not well understood despite numerous studies. It is a specific entity, not always resulting from natural history of acute appendicitis. In our practice, appendicitis is frequently managed when complicated such as an abscess or peritonitis. The clinical presentation and white blood cell count gave orientation for the type of complication, while the patient’s age and symptoms’ duration did not. In our context, morbidity and mortality of this disease remains a challenge.