Diagnosing Children with Appendicitis

A Case Example

The patient, in this case, is a child with learning difficulties. The patient became unwell with stomach pain. The claimants parent contacted out of hours and an appendicitis was suspected. At the hospital the patient had abdominal pain and was walking hunched over. It was also noted in records that the patient looked bright and well. A diagnosis of non-specific abdominal pain was made and the patient discharged. Later that day, on further presentation to A&E, a diagnosis of constipation was made.

The patient’s symptoms included: abdominal pain, being off their food; vomiting and being sleepy. The patient was pyrexial and had diffuse abdominal tenderness worse in the lower quadrants.

They were discharged and re-presented a week later with on going abdominal pain and a raised temperature. On this occasion they were admitted over night, but discharged the following morning. They then re-presented later that day when they were diagnosed with suspected appendicitis. At laparoscopic appendicectomy surgery, there was a palpable mass, an abscess cavity in the right iliac fossa, and a perforated appendix.

The main learning points from this review stem from the following events:

  • Not fully investigating the patient’s symptoms, in particular elevated temperature, high pulse rate, persistent abdominal pain with associated vomiting and tenderness to the right lower quadrant;
  • Discharging the patient after their second presentation on the first day.

Recommendations to Prevent Incident Recurrence and Improve Patient Safety

TMLEP’s recommendations to reduce recurrence and enhance patient safety are as follows:

  • Clinicians should be aware of the red flags of appendicitis. This should include further education on the symptoms and signs to look out for and when appropriate further investigation with blood tests and imaging are required. This is important in the case of children as appendicitis is the most common cause of abdominal pain in young children.
  • It should be noted that children with developmental delay, learning difficulties, attention deficit hyperactivity disorder or autism are groups that are particularly difficult to assess.
  • The classic symptoms are of appendicitis are:
  • Abdominal pain — this is the primary presenting complaint, and it is typically described as a periumbilical or central pain that worsens during the first 24 hours (initially intermittent then constant) and migrates to the right iliac fossa (RIF). The pain is typically aggrevated by movement and coughing.
  • Anorexia — almost always present.
  • Nausea.
  • Vomiting (profuse vomiting may indicate development of peritonitis).
  • Constipation or diarrhoea.
  • On examination, there may be:
  • Tenderness on palpation, +/-guarding, and rebound tenderness in the RIF — these are the most reliable clinical findings.
  • Facial flushing, dry tongue, halitosis, low-grade fever (usually not more than 38°C), and/or tachycardia.

  • It is recommended that history of learning difficulties and young age highlights a potential for difficulties in clinical assessment. It should be acknowledged that children with abdominal pain and learning difficulties can be difficult to assess and there is an increased risk of a misdiagnosis of intraabdominal pathology. Clinicians should ensure that patient’s symptoms are fully considered in the context of the history, along with their age. In this case, the patients symptoms of abdominal pain, anorexia, vomiting and signs of pyrexia and diffuse abdominal tenderness, together with their young age and learning difficulties should have prompted further investigation and consideration of appendicitis.

  • It is recommended clinicians have a lower threshold for investigation/admission to hospital for appendicitis in this patient group. In addition, it is recommended clinicians ensure that if clinical features indicate it is necessary or there is diagnostic uncertainty, further investigation with blood tests and potentially an abdominal ultrasound are arranged, this is especially important if there are difficulties in preliminary clinical assessment.


In summary, appendicitis accounts for more than 40,000 hospital admissions in England every year. It is one of the most common causes of abdominal pain in young adults and children in the UK. This case highlights the importance in taking symptoms fully into consideration. All the clinical symptoms of the patient should be thoroughly assessed, so as to ensure that diagnosis takes place as early possible. Not only is it important to consider all the symptoms and signs, but it is also important to ensure that appropriate investigations are arranged following clinical examinations.

TMLEP would like to emphasise clinicians need to have a lower threshold for further investigation/admission to hospital for possible appendicitis in this patient group.