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Hopkins children's experts say doctors and parents can sort out symptoms with a checklist

October 07, 2008

A young child arrives at the emergency room after several days of abdominal pain, vomiting, and diarrhea and is sent home with a diagnosis of viral gastritis and treatment for the symptoms. The child seems better for a while, only to return to the ER with worse symptoms and a ruptured appendix, a life-threatening complication of appendicitis.

The scenario is not uncommon, experts say, because children with appendicitis don't usually have the classic symptoms of the condition, but pediatricians at the Johns Hopkins Children's Center say there are ways for doctors and parents to tell the difference early on between a potentially deadly burst appendix - which can kill in a matter of days, even hours - and a stomach bug.

Past research has found that half of appendicitis cases are misdiagnosed when they first present at the emergency room or the doctor's office and that up to 80 percent of appendicitis cases in children younger than 4 years of age end up in rupture.

Says emergency room pediatrician Jennifer Anders, M.D., of Hopkins Children's, who has seen her fair share of burst appendixes, "appendicitis should always be near the top of the list of potential culprits when a child has any abdominal pain, vomiting, and malaise," keeping in mind that many children don't have fever or lose appetite the way adults might.

Doctors recommend that children with prolonged or severe abdominal symptoms that do not go away or improve should be evaluated for ruptured appendix. Consider the following questions:

* Do blood tests indicate elevated white cell count?

* Does the child have diarrhea? Diarrhea, which can be a marker of bowel inflammation resulting from the infection caused by the burst appendix, often distracts doctors and puts them on a different track. Diarrhea may not be a classic sign of appendicitis, but it may signal a ruptured appendix.

* Did the child have vomiting, which later stopped?

* Was there sharp pain in the lower right portion of the abdomen, which later subsided and became dull and spread across the abdominal area? Paradoxically, as appendicitis worsens and the appendix ruptures, the acute pain is alleviated and transformed into more diffuse abdominal pain.

"It's counter-intuitive, but if that sharp pain improves or subsides and becomes more generalized, it's actually a bad sign," Anders says.

The appendix is a small tube extending from the large intestine, and infections and inflammation of the organ can be dangerous. The only absolute way to diagnose the condition is surgery, and each year, appendicitis sends 77,000 American children to the hospital. An estimated one-third of them suffer a ruptured appendix before they reach the OR.

Johns Hopkins Medical Institutions