Of 6,099 children treated for
malignancy, 16 (ages 3.5 to 18 years) developed acute
appendicitis between 1962 and 1989. Fourteen had
leukemia (ALL 10, AML 4). One each had
rhabdomyosarcoma and
Ewing's sarcoma. Active
malignancy at diagnosis was noted in 10, 4 of whom had severe
neutropenia (absolute neutrophil count less than 500/mm3). Of all the leukemics (2,794/6,099),
abdominal pain during induction was a frequent complaint. The incidence of
appendicitis, however, was low (0.5%). Nine of the 16 patients presented classically, facilitating prompt diagnosis and treatment. Six diagnoses were delayed. Three of these patients presented atypically with vague, nonlocalized
pain, abdominal distention, lack of abdominal guarding,
fever,
dehydration,
diarrhea, and unusual symptoms such as upper gastrointestinal
bleeding. In each of these 6 patients the appendix was ruptured. Delays led to complications and deaths. Three patients required perioperative transfusions to treat excessive
bleeding and two patients with
ruptured appendicitis developed
wound abscesses. Two patients died; in one, ruptured appendix was diagnosed only at autopsy. The other patient died of uncontrolled
sepsis.
Typhlitis occurring during
induction chemotherapy may present similarly and is the main differential diagnosis.
Typhlitis will usually improve with medical treatment alone.
Nausea and
vomiting (13/16), right lower quadrant
pain (13/16), guarding (14/16),
tachycardia (12/16),
fever (10/16), and rebound tenderness (10/16) were the most frequent signs and symptoms of
appendicitis. Persistent localized
abdominal pain and guarding, lack of improvement with medical treatment,
clinical deterioration, and the development of a mass were our indications for
laparotomy. Despite major improvements in
therapy, there is still a 37.5% error rate in our ability to accurately diagnose
appendicitis in pediatric
cancer patients.