The Implications of Missed Opportunities to Diagnose Appendicitis in Children

Authors

  • Jessica A. Naiditch MD,

    1. Division of Pediatric Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL
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  • Timothy B. Lautz MD,

    1. Division of Pediatric Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL
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  • Susan Daley MD,

    1. Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL
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  • Mary Clyde Pierce MD,

    1. Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL
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  • Marleta Reynolds MD

    Corresponding author
    • Division of Pediatric Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL
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  • The authors have no relevant financial information or potential conflicts of interest to disclose.

Address for correspondence and reprints: Marleta Reynolds, MD; e-mail: MReynolds@luriechildrens.org.

Abstract

Objectives

The purpose of this study was to determine the fraction of children with acute appendicitis who had recent false-negative diagnoses and to analyze the association of a missed diagnosis of appendicitis with patient outcome.

Methods

The records of all 816 patients who underwent appendectomy for suspected appendicitis at a free-standing children's hospital between 2007 and 2010 were reviewed. A patient admitted or evaluated in the emergency department (ED), discharged without a diagnosis of appendicitis, and then readmitted with histopathologically confirmed appendicitis within 3 days was considered to have a “missed diagnosis.” Outcomes for this missed group were compared to those of the remainder of the appendectomy cohort.

Results

Thirty-nine patients with appendicitis (4.8%) were missed at initial presentation. The most common initial discharge diagnoses were acute gastroenteritis (43.6%), constipation (10.3%), and emesis (10.3%). The median duration from the initial evaluation to the appendicitis admission was 28.3 hours (interquartile range [IQR] = 17.0 to 39.6 hours). A missed diagnosis was associated with a longer median hospitalization (5.8 days [IQR = 4.0 to 8.1 days] vs. 2.5 days [IQR = 1.8 to 4.6 days]; p < 0.001), higher rate of perforation (74.4% vs. 29.0%; p < 0.001), higher complication rate (28.2% vs. 10.4%; p = 0.002), and higher rate of reintervention (20.5% vs. 6.2%; p = 0.003).

Conclusions

Of children diagnosed with appendicitis, 4.8% may have had a missed opportunity for earlier diagnosis. These false-negative diagnoses are associated with higher rates of perforation, postoperative complications, and need for postoperative interventions, as well as longer hospitalizations.

Resumen

Las Implicaciones de las Oportunidades Perdidas para Diagnosticar Apendicitis en Niños

Objetivos

El propósito de este estudio fue determinar el porcentaje de niños con apendicitis aguda que tuvieron un diagnóstico falso negativo, y analizar la asociación de un diagnóstico perdido de apendicitis con los resultados del paciente.

Metodología

Se revisaron las historias clínicas de todos los 816 pacientes en los que se llevó a cabo una apendicectomía por sospecha de apendicitis en un hospital pediátrico entre 2007 y 2010. Se consideró tener “un diagnóstico perdido” a aquellos pacientes ingresados o evaluados en el servicio de urgencias (SU), dados de alta sin el diagnóstico de apendicitis y después reingresados con apendicitis confirmada histopatológicamente en los tres primeros días. Los resultados de este grupo perdido se compararon con el resto de la cohorte de apendicectomía.

Resultados

Treinta y nueve pacientes con apendicitis (4,8%) se perdieron en la atención inicial. Los diagnósticos iniciales de alta más comunes fueron gastroenteritis aguda (43,6%), estreñimiento (10,3%) y vómitos (10,3%). La mediana de duración desde la evaluación inicial hasta el ingreso por apendicitis fue de 28,3 horas (RIC 17,0 a 39,6 horas). Un diagnóstico perdido se asoció con una mediana de hospitalización más prolongada (5,8 días [RIC 4,0 a 8,1 dias] vs 2,5 días [RIC 1,8 a 4,6 dias] p < 0,001) y unos porcentajes mayores de perforación (74,4% vs. 29,0%; p < 0,001), complicación (28,2% vs 10,4%; p = 0,002) y reintervención (20,5% vs. 6,2%; p = 0,003).

Conclusiones

De los niños diagnosticados con apendicitis, un 4,8% pueden haber tenido una oportunidad perdida para el diagnóstico precoz. Estos diagnósticos falsos negativos se correlacionan con mayores porcentajes de perforación, complicaciones postoperatorias y la necesidad de reintervenciones, así como con un mayor tiempo de hospitalización.

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