# Case Report: Diagnostic challenges in pediatric appendicitis: a case of perforated appendicitis with secondary hepatic abscess

## TL;DR

A 4-year-old girl with atypical symptoms of appendicitis was initially misdiagnosed but later found to have a perforated appendix causing a liver abscess.

## Contribution

This case emphasizes the importance of re-evaluation and broad differential diagnosis in atypical pediatric appendicitis presentations.

## Key findings

- Initial abdominal ultrasound failed to detect appendicitis in a young child.
- Persistent symptoms and elevated inflammatory markers led to the discovery of a secondary hepatic abscess.
- Laparoscopic surgery confirmed perforated appendicitis and resolved the abscess.

## Abstract

Appendicitis in young children (age <5 years) frequently presents with atypical symptoms, creating diagnostic challenges in primary care and emergency settings. This report describes a 4-year-old girl who presented to the emergency department with fever, vomiting, and abdominal pain. Initial evaluation including abdominal ultrasound showed no evidence of appendicitis, and she was discharged with a presumptive diagnosis of viral gastroenteritis. Five days later, she was readmitted with persistent symptoms and markedly elevated inflammatory markers. Advanced imaging revealed a hepatic abscess, initially attributed to primary liver pathology. Diagnostic laparoscopy ultimately revealed perforated appendicitis with secondary hepatic abscess. The patient underwent successful laparoscopic appendectomy and abscess drainage with complete recovery. This case highlights the essential clinical approach of maintaining a broad differential diagnosis, recognizing the limitations of imaging, and mandating systematic re-evaluation with structured follow-up when a patient's expected clinical improvement fails to materialize.