title: Pitfalls in paediatric appendicitis: Highlighting common clinical features of missed cases.
abstract: OBJECTIVE
  Missed cases of paediatric appendicitis lead to a delay in diagnosis and increased complications during the subsequent surgery. We aim to identify the common clinical features of such cases at the time of first hospital attendance.
  
  
  METHODS
  Case records of patients with a missed diagnosis were reviewed retrospectively, documenting the presentation, preliminary investigations, initial diagnosis and eventual outcome.
  
  
  RESULTS
  Thirty-nine patients fitted our criteria over a 2-year and 5-month period. The rate of "missed appendicitis" was 7%. The commonest symptoms and signs were that of nausea and vomiting (74.4%), abdominal pain (74.4%) and fever (61.5%). The site of abdominal pain was rarely in the right iliac fossa (5.1%). The two commonest diagnoses made at first presentation was that of gastroenteritis (51.3%) and constipation (25.6%). Twenty patients (51.3%) were initially discharged home. Compared to those initially admitted, more of those initially discharged home underwent surgery delayed beyond 24 hours from first presentation.
  
  
  CONCLUSIONS
  The paucity of symptoms and signs in the right lower quadrant does not exclude appendicitis. Gastroenteritis and colic constipation are the greatest masqueraders of paediatric appendicitis. A high index of suspicion, therefore, is necessary to avoid wrongful discharge altogether.
authors.affiliation: Department of Emergency Medicine, KK Women's and Children's Hospital, Singapore. melanie_SEAH@ttsh.com.sg
authors.forename: Melanie D W
authors.initials: MD
authors.lastname: Seah
authors.forename: Kee-Chong
authors.initials: KC
authors.lastname: Ng
mesh_terms: D015746:Abdominal Pain / Q000175:diagnosis; D000293:Adolescent; D000367:Age Factors; D001064:Appendicitis / Q000175:diagnosis* / Q000601:surgery; D002648:Child; D002675:Child, Preschool; D003085:Colic / Q000175:diagnosis; D003248:Constipation / Q000175:diagnosis; D003937:Diagnosis, Differential; D005260:Female; D005759:Gastroenteritis / Q000175:diagnosis; D006801:Humans; D007223:Infant; D008297:Male; D012189:Retrospective Studies; D012737:Sex Factors; D013997:Time Factors