The number of children under 15 years of age certified as dying of acute appendicitis each year in England and Wales decreased from the 1930s to the 1980s. Factors contributing to death have been analysed in audits in 1963-7 and 1980-4.1,2 We undertook an audit of children dying in 1993-7, compared these results with those of previous audits, examined hospital administrative statistics,3 and identified possible reasons for the fall in the number of deaths.
Methods and results
We used similar methods to previous audits to examine hospital and coroner's reports of all 12 childhood deaths in 1993-7.1,2 The median age of the children who died was 10.6 (range 3.0-14.2) years. Six children died at home or on arrival at hospital, and six died postoperatively in hospital from multiorgan failure (four in district general hospitals, two in children's hospitals). Median duration of symptoms before hospital admission or death was 3 (2-6) days. Difficulty or delay in diagnosis was the main factor contributing to death in six cases.
The number of deaths from acute appendicitis in hospital fell from an annual average of 36.2 in 1963-7 to 1.8 in 1993-7. The case fatality rate in hospital has fallen from 1.06 to 0.16 per 1000 discharges with acute appendicitis, a fall of 85% (table). If children who were moribund on arrival at hospital are excluded the decrease is 97%. If the 1963-7 age specific death rates had applied to children admitted with acute appendicitis in 1993-7 the expected number of deaths would have been 50 rather than the nine recorded. Thus 41 of 172 (24%) fewer deaths in 1993-97 may be attributed to a fall in the hospital case fatality rate, the greatest improvement being in the youngest age group.
The number of children with a discharge diagnosis of “acute appendicitis” fell from an annual average of 34 000 in 1963-7 to 11 500 in 1993-7; the discharge rate fell from 3117 to 1153 per million children (63% fall). The discharge rate for children with “operations on the appendix” decreased by 60%, and the rate for children with a discharge diagnosis of “abdominal pain” increased by 88%. The population of children aged 0-14 years decreased by 8.5%.
Comment
Three quarters of the dramatic fall in the number of children dying of acute appendicitis during the past 30 years is due to a decrease in the incidence of appendicitis in a slightly smaller child population. A quarter of the fall is due to a marked decline in the hospital case fatality rate, probably reflecting improved medical care. In the 1960s the main factors contributing to death were inadequate fluid replacement, anaesthetic complications, hyperpyrexia, convulsions, sepsis, and difficulty or delay in diagnosis. Difficulty or delay in diagnosis is now the main factor contributing to the small number of deaths.
The recorded decline in discharges for acute appendicitis has been noted in other studies, and the parallel rise in discharges for abdominal pain suggests that some of this fall is due to improved diagnosis. The combined impact of computer aided diagnosis, clinical scoring systems, ultrasonography, laparoscopy, and cross sectional imaging techniques remains uncertain. Clinical assessment and “active observation” still have a vital role in the diagnosis of acute appendicitis.4
The reason for the declining incidence of acute appendicitis is unknown. It has been attributed to improved hygiene and changing patterns of childhood infection resulting in less lymphoid hyperplasia in the gut.5 It is intriguing that such a dramatic reduction in the number of cases of a serious and worrying illness has come about for reasons that are not clear and without any national strategy.
Table.
Death rates per 1000 discharges (actual number of deaths) in hospital from acute appendicitis in England and Wales
| Age (years)
|
||||
|---|---|---|---|---|
| 0-4 | 5-9 | 10-14 | All | |
| Period | ||||
| 1963-7 | 6.5 (71) | 0.96 (56) | 0.53 (54) | 1.06 (181) |
| 1980-4 | 3.13 (8) | 0.35 (8) | 0.15 (9) | 0.30 (25) |
| 1993-7 | 0.44 (1) | 0.12 (2) | 0.15 (6) | 0.16 (9) |
| Fall in death rate (%) | ||||
| 1963-97 | 93 | 87 | 72 | 85 |
Acknowledgments
We thank the consultants and coroners who kindly responded to our requests for information and Professor Richard Thomson for helpful advice.
Footnotes
Funding: Charges for obtaining death certificates from the Office for National Statistics were paid with funds donated for paediatric surgical research.
Competing interests: None declared.
References
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