Fatal Appendicitis Could Have Been Detected Earlier: Pediatric Surgery Expert


Internal Medicine Expert WitnessThis case involves a 4-month-old girl who presented to the ER with multiple symptoms, including a visibly distended abdomen. An ultrasound was performed, however it was noted that the testing did not visualize the appendix. Because of this, and the young age of the child, the surgeon ruled out appendicitis and considered other explanations for the patient’s condition, which continued to deteriorate over the course of the next few days. Eventually, the patient died in the hospital, with the cause of death identified as a ruptured appendix. It was alleged that the patient should have been diagnosed with and treated for appendicitis shortly after her arrival at the hospital.

Question(s) For Expert Witness

  • 1. Do you have extensive experience treating patients who present with signs of appendicitis?
  • 2. Are you familiar with the sign and symptoms that are present when appendicitis is the issues?

Expert Witness Response E-009839

Appendicitis is uncommon in children under 6 months of age, but it should always be considered as part of the differential diagnosis. An abdominal ultrasound should be interpreted with caution. Acute appendicitis can only be excluded on ultrasound examination if it is clearly visualized, and normal in appearance (normal diameter, compressible, with no sonographic evidence of inflammation). I have extensive experience in both the diagnosis and treatment of patients with both simple uncomplicated appendicitis and complex cases. I perform approximately 100 appendectomies every year, and have done so since 2006. I am a pediatric surgeon champion for the American College of Surgeons national surgical quality improvement program (NSQIP), and our institution has been participating in the appendectomy pilot study which has established best practices for pediatric appendicitis.

Expert Witness Response E-006745

Expert-ID: E-006745

It is extremely rare to have a child so youngwith perforated appendicitis, and that it would certainly not be high on any pediatric surgeon’s differential upon a child’s initial presentation to an ER with the symptoms described here. However, if the child was deteriorating over the ensuring days, then perhaps a consideration for going to the operating room should have been entertained based on the child’s exam and clinical status — had they gone to the operating room based on other clinical findings, then this may have avoided the mortality. But again, as an initial presentation in the ER, no pediatric surgeon would think a child this young had appendicitis based on an ultrasound showing these findings — that does not mean that after a longer period of the child worsening that perhaps more aggressive measures should have been considered.

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