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<p>Perforated appendicitis remains one of the most important causes of preventable morbidity in pediatric surgery. Despite substantial advances in diagnostic imaging, laboratory biomarkers, and clinical scoring systems, delayed diagnosis continues to contribute significantly to perforation, postoperative complications, prolonged hospitalization, and increased healthcare utilization. Emerging evidence suggests that delayed diagnosis is a multifactorial process involving patient-related, physician-related, and healthcare system-related factors rather than a single-point clinical failure. To critically evaluate the multidimensional causes of diagnostic delay in pediatric appendicitis and to develop a clinically applicable framework aimed at facilitating earlier recognition and reducing the risk of perforation. A structured narrative review was conducted using PubMed, Scopus, and Web of Science databases. Studies published between January 2000 and March 2026 evaluating pediatric appendicitis, perforation, diagnostic delay, imaging strategies, biomarkers, and clinical decision-making were reviewed. Eligible studies included original research articles, systematic reviews, clinical practice guidelines, and relevant peer-reviewed studies involving pediatric populations. Evidence was synthesized using a thematic framework encompassing patient-related, physician-related, and healthcare system-related determinants of delayed diagnosis. Diagnostic delay in pediatric appendicitis results from the cumulative interaction of multiple factors. Patient-related contributors include young age, atypical symptom presentation, communication limitations, and delayed healthcare-seeking behavior. Physician-related factors include diagnostic uncertainty, cognitive bias, and overreliance on isolated laboratory or imaging findings. Healthcare system-related factors such as limited access to pediatric surgical expertise, emergency department crowding, imaging delays, and variability in institutional pathways further prolong diagnostic timelines. Based on the synthesized evidence, a clinically applicable diagnostic framework emphasizing risk stratification, serial reassessment, timely imaging, and early surgical consultation was developed. Missed perforated appendicitis should be viewed as the consequence of cumulative delays occurring across multiple stages of care. Reducing perforation rates requires an integrated approach combining heightened clinical vigilance, structured diagnostic pathways, repeated clinical assessment, and timely access to pediatric surgical expertise. The proposed framework may help standardize evaluation and reduce preventable morbidity in children with suspected appendicitis.</p>

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Why do Children still Develop Perforated Appendicitis? A Structured Narrative Review and Clinical Framework for Reducing Diagnostic Delays

  • 期刊论文

  • 发表日期：

    2026年7月14日

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摘要

Perforated appendicitis remains one of the most important causes of preventable morbidity in pediatric surgery. Despite substantial advances in diagnostic imaging, laboratory biomarkers, and clinical scoring systems, delayed diagnosis continues to contribute significantly to perforation, postoperative complications, prolonged hospitalization, and increased healthcare utilization. Emerging evidence suggests that delayed diagnosis is a multifactorial process involving patient-related, physician-related, and healthcare system-related factors rather than a single-point clinical failure. To critically evaluate the multidimensional causes of diagnostic delay in pediatric appendicitis and to develop a clinically applicable framework aimed at facilitating earlier recognition and reducing the risk of perforation. A structured narrative review was conducted using PubMed, Scopus, and Web of Science databases. Studies published between January 2000 and March 2026 evaluating pediatric appendicitis, perforation, diagnostic delay, imaging strategies, biomarkers, and clinical decision-making were reviewed. Eligible studies included original research articles, systematic reviews, clinical practice guidelines, and relevant peer-reviewed studies involving pediatric populations. Evidence was synthesized using a thematic framework encompassing patient-related, physician-related, and healthcare system-related determinants of delayed diagnosis. Diagnostic delay in pediatric appendicitis results from the cumulative interaction of multiple factors. Patient-related contributors include young age, atypical symptom presentation, communication limitations, and delayed healthcare-seeking behavior. Physician-related factors include diagnostic uncertainty, cognitive bias, and overreliance on isolated laboratory or imaging findings. Healthcare system-related factors such as limited access to pediatric surgical expertise, emergency department crowding, imaging delays, and variability in institutional pathways further prolong diagnostic timelines. Based on the synthesized evidence, a clinically applicable diagnostic framework emphasizing risk stratification, serial reassessment, timely imaging, and early surgical consultation was developed. Missed perforated appendicitis should be viewed as the consequence of cumulative delays occurring across multiple stages of care. Reducing perforation rates requires an integrated approach combining heightened clinical vigilance, structured diagnostic pathways, repeated clinical assessment, and timely access to pediatric surgical expertise. The proposed framework may help standardize evaluation and reduce preventable morbidity in children with suspected appendicitis.