S. Huang1, 2, A. E. Figueroa1, 2, S. Shah1, 2, P. Bhattarai1, 2, K. Mitaszka1, 2, M. K. Wallack1, 2, J. G. Mariadason1, 2 1Metropolitan Hospital Center, Surgery, New York, NEW YORK, USA 2New York Medical College, Valhalla, NY, USA
Introduction:
Historically, appendicoliths (fecaliths) were believed to be the main cause of appendicitis in adults while lymphoid hyperplasia was thought to be the usual culprit in children. However, it has become apparent that acute appendicitis associated with appendicoliths may be more prevalent in the pediatric population than in adults; 29.9% compared to 13.7% for adults in one study (1). The presence of appendicoliths is associated with perforation in several studies. In the adult population non-operative management has become a popular option except when a fecalith is present for this reason. Our study seeks to uncover whether prevalence of appendicoliths changes from early childhood to adulthood.
Methods:
We retrospectively reviewed charts of all patients who underwent appendectomy for acute appendicitis at Metropolitan Hospital Center between January 2010 to December 2019. We separated the patients into pediatric (<19) and Adult (≥ 19). We further sub-stratified our pediatric cohort into preschoolers (ages 1-4), elementary schoolers (5-12) and teenagers (13-18). The presence of appendicoliths was identified with pathology report. We also investigated our negative appendectomy rate for all comers.
Results:
Out of 855 patients who underwent an appendectomy for appendicitis, 23.5 % (201/855) were identified as pediatric, 1.63% (14/855) were preschoolers, 12.5% (107/855) elementary schoolers and 9.4% (80/855) teenagers. Our adult population comprised the remaining 76.5% (654/855). The prevalence of appendicoliths for each group was calculated; 64.3% (9/14) for preschoolers; 32.7% (35/107) for elementary schoolers, 26% (21/80) teenagers and 18.65% (122/654) for adults. The overall negative appendectomy rate was 3% over the past 20 years.
Conclusion:
A clear pattern of diminishing prevalence of appendicoliths with increasing age emerged. This is in contradistinction to the long-held view that appendicoliths are the primary etiology of adult appendicitis while lymphoid hyperplasia was the main cause in children. It affirms an observation made in a previous study from our institution, and additionally, is the first study to demonstrate that prevalence of appendicoliths in acute appendicitis is highest in toddlers and gradually diminishes with age. As such, these results beg a follow-up question: During the COVID pandemic with nonoperative management of uncomplicated appendicitis gaining popularity for adults, is it a viable option for pediatric cases as well? While non operative management may be a viable option for teenagers who essentially behave like adults and have a lower appendicolith incidence, for younger children with higher appendicolith rates and less reliable imaging, surgery likely remains the safest option.
