Pediatric Surgery Experts Discuss Delayed Treatment of Ruptured Appendix

Surgery Expert WitnessThis case involves a 5 year old girl who presented to the ER with fluid in her abdominal cavity as well as a distended stomach in Utah. An ultrasound was performed, however it was noted that it did not visualize the appendix. Because of this, and the young age of the child, the surgeon ruled out appendicitis and considered other, more esoteric, explanations for her symptoms and worsening condition over the next several days. The child’s appendix eventually burst, causing a massive infection and necessitating an extended hospital stay.

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 issue?

Expert Witness Response E-006745

Expert-ID: E-006745

What I would say is that it is extremely rare to have a child of this age with 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 these symptoms. 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. Once committed to going to the operating room, most surgeons would still not expect to be finding appendicits in this scenario, but probably had they gone to the operating room based on other clinical findings, then this may have avoided additional injuries. But again, as an initial presentation in the ER, no pediatric surgeon would think this child had appendicitis based on an ultrasound showing ascites — that does not mean that after 24 hours of the child worsening that perhaps more aggressive measures should have been considered.

Expert Witness Response E-009839

Appendicitis is uncommon in children of this 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.


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