This is a cohort study analyzing patients who presented to the ED with undifferentiated symptoms associated with appendicitis over the course of 8 years.

Appendicitis is one of the most common surgical emergencies in the U.S., but this diagnosis is missed in up to 15% of children and 23.5% of adults.

Previous studies have found that factors such as constipation in children, female sex, and patient age (<5 or >50) were also associated with a delayed or missed appendicitis diagnosis.

The population for this study included adults (> 18) and children (< 18 who were diagnosed with appendicitis. From there they identified ED visits where patients presented with undifferentiated symptoms that are associated with appendicitis

• A “missed diagnosis” was wan initial ED visit at which a patient presented with any single undifferentiated symptom or combination of undifferentiated symptoms associated with appendicitis for which the patient did not receive a diagnosis of appendicitis on the same day of the symptom presentation

After the analysis of data, these are the factors associated with missed diagnosis of appendicitis:

• Female sex and higher comorbidity index were associated with potentially missed appendicitis in both children and adults
• Additionally, patients were more likely to have a missed diagnosis if abdominal radiography was used for imaging—regardless of age (usually because providers using xrays are probably not suspecting appendicitis)
• Abdominal pain, the most common presenting symptom with or without associated symptoms, is closely associated with appendicitis—however, abdominal pain is one of the leading causes of return visits to the ED due to diagnostic error
• Although observations of racial and ethnic disparities in healthcare in general and the ED are not new, only 1 previous study of missed appendicitis included race in the analysis, and it did NOT find race to be associated with missed appendicitis—however, the article made it clear that this area of disparity requires more attention and further studies
• The probability of missed appendicitis for an Asian man aged 41-60 years who presents to the ED with abdominal pain and no comorbid condition is 2.8%. On the other hand, a black woman aged 18-25 with abdominal pain and 2 or more comorbid conditions would have a probability of missed appendicitis of 22.9%

Conclusion: Regardless of age, a missed diagnosis of appendicitis was more likely to occur in female patients, patients with comorbidities, and patients with abdominal pain accompanied by constipation. These are definitely areas where we as providers can educate ourselves on and become more diligent in identifying when assessing our patients so we don’t make that mistake of missing a critical diagnosis.