Introduction
Appendicitis is the second most common acute abdominal inflammatory problem in childhood (1). It is also the most common disease process requiring surgery in childhood. (2,3). Diagnosis in children can be elusive because as many as 30-45% of patients present with atypical symptoms (4). Perforated appendicitis is more common in children than in adults, and is associated with increased morbidity (5). It can mask the typical symptoms of acute appendicitis and delay the diagnosis.(5). Knowledge of the typical pathophysiologic sequence of appendicitis will be useful in making the clinical diagnosis in only 70 -75 % of the children with appendicitis.(3). This is because an accurate history and sequential examination of a child is not possible in many instances. However the goal in the clinical care of acute appendicitis is to make the diagnosis before perforation occurs (5). The progression of acute appendicitis to perforation is more rapid in the younger child, sometimes occurring within 6-12 hours (6). The risk of perforation within 24 hours of symptom onset is less than 30%; after 48 hours, the risk of perforation increases to greater than 70%(5). The perforation rate and the false negative appendectomy rate may be reduced through enhanced understanding of the natural history of appendicitis and its variable presentation in children.