The risk of perforation when children with possible appendicitis are observed in the hospital.

The morbidity rate from perforation demands that appendicitis be diagnosed promptly in children with abdominal pain. Although admitting and observing uncertain instances of appendicitis can refine the diagnostic accuracy, it is often claimed, but not proved, that this necessitates increasing the number of perforations. To assess the risk of perforation while observing uncertain instances of childhood appendicitis, we admitted 150 consecutive referrals during a period of one and one-half years. Immediate appendectomy was performed for 74 patients (49 percent) with convincing clinical signs and symptoms for appendicitis. The remaining 76 (51 percent) with unconvincing clinical signs and symptoms were observed as inpatients. One-third of the patients admitted for observation (26 of 76) underwent appendectomy after an average period of 12 hours. Two-thirds (50 of 76) of the patients got better and were discharged from the hospital without an appendectomy after an average admission of two days. Seven of the 100 appendices removed were normal. Three of the observed patients had perforations, one of whom may have perforated during observation, but that child went on to do well. The 50 patients who got well without appendectomy were similar to the patients with appendicitis, but significantly less likely to have peritoneal signs (8 versus 70 percent), tenderness in the right lower quadrant (48 versus 81 percent) and guarding (19 versus 75 percent). We conclude that admission and active observation in the hospital of children with possible, but unconvincing, signs and symptoms of appendicitis is a safe and effective way to determine which patients need an operation.