Diagnostic challenges of acute appendicitis in preschool children: A comprehensive case-control study

Aim: Acute appendicitis is a common surgical emergency in children, yet it poses diagnostic challenges in preschool children due to atypical presentation. This case-control study aims to evaluate the distinct characteristics of acute appendicitis in preschool compared to school-aged children. Methods: Children under 5 years and a control group of children aged 5–10 years, operated on due to acute appendicitis at our institution during 2009–2022 were included. Data on demographics, clinical presentation, laboratory results, imaging, surgical procedure, pathology, bacteriology, antibiotic treatment, length of stay and outcomes were collected retrospectively. Results: A total of 184 preschool and 187 school-aged children were included. Preschool children presented less frequently with abdominal pain but more often with vomiting, diarrhoea and fever. Preschool children had lower rates of leucocytosis but higher thrombocytosis and C reactive protein. Younger patients were more likely to undergo both chest and abdominal X-rays and be admitted to a paediatric department before diagnosing appendicitis. Complicated appendicitis, requiring increased use of intra-operative drain placement, and conversions to open procedures were more common in preschool children, with higher rates of ICU admission and surgical complications. Polymicrobial positive cultures and positive cultures for Bacteroides were more common in preschool children. Conclusions: This study highlights the critical need for increased awareness among healthcare providers regarding the diagnostic challenges posed by atypical presentations of acute appendicitis in preschool children. Despite comprehensive evaluation, diagnosis in this age group may be difficult, emphasising the significance of recognising these presentation patterns to improve diagnostic accuracy and prompt management.