Appendicitis (peds): Difference between revisions
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===Neonates=== | ===Neonates=== | ||
*History | *History | ||
**Vomiting | **[[Nausea and vomiting (peds)|Vomiting]] | ||
**Irritability/lethargy | **Irritability/[[altered mental status (peds)|lethargy]] | ||
*Physical | *Physical | ||
**Abdominal distention | **Abdominal distention | ||
===Infants (30 days - 2 yrs)=== | ===Infants (30 days - 2 yrs)=== | ||
*History | *History | ||
**Vomiting | **[[Nausea and vomiting (peds)|Vomiting]] | ||
**Abdominal pain | **[[Abdominal pain (peds)|Abdominal pain]] | ||
**Fever | **[[Fever (Peds)|Fever]] | ||
*Physical | *Physical | ||
**Diffuse abdominal tenderness | **Diffuse abdominal tenderness | ||
| Line 26: | Line 26: | ||
===Preschool (2 - 5yrs)=== | ===Preschool (2 - 5yrs)=== | ||
*History | *History | ||
**Vomiting (often precedes pain) | **[[Nausea and vomiting (peds)|Vomiting]] (often precedes pain) | ||
**Abdominal pain | **[[Abdominal pain (peds)|Abdominal pain]] | ||
**Fever | **[[Fever (Peds)|Fever]] | ||
*Physical | *Physical | ||
**RLQ tenderness | **RLQ tenderness | ||
===School-age (6 - 12yrs)=== | ===School-age (6 - 12yrs)=== | ||
*History | *History | ||
**Vomiting | **[[Nausea and vomiting (peds)|Vomiting]] | ||
**Abdominal pain | **[[Abdominal pain (peds)|Abdominal pain]] | ||
**Fever | **[[Fever (Peds)|Fever]] | ||
*Physical | *Physical | ||
**RLQ tenderness | **RLQ tenderness | ||
| Line 41: | Line 41: | ||
*Present similar to adults | *Present similar to adults | ||
**RLQ pain | **RLQ pain | ||
**Vomiting (occurs after onset of abdominal pain) | **[[Vomiting]] (occurs after onset of abdominal pain) | ||
**Anorexia | **Anorexia | ||
| Line 104: | Line 104: | ||
*NPO | *NPO | ||
*[[IVF]] (20 mL/kg boluses) | *[[IVF]] (20 mL/kg boluses) | ||
*Analgesia | *[[Analgesia]] | ||
**[[Ketorolac]] | **[[Ketorolac]] | ||
**[[Morphine]] | **[[Morphine]] | ||
| Line 110: | Line 110: | ||
**[[Ampicillin/sulbactam]] '''OR''' [[cefoxitin]] | **[[Ampicillin/sulbactam]] '''OR''' [[cefoxitin]] | ||
**Penicillin allergy? | **Penicillin allergy? | ||
***[[ | ***[[Gentamicin]] + ([[clindamycin]] '''OR''' | ||
***[[metronidazole]]) | ***[[metronidazole]]) | ||
**Perforation or complicated appendicitis<ref>Yardeni D et al. Single daily dosing [[ceftriaxone]] and [[metronidazole]] vs standard triple antibiotic regimen for perforated appendicitis in children: a prospective randomized trial. J Pediatr Surg. 2008 Jun; 43(6): 981–985.</ref> | **Perforation or complicated appendicitis<ref>Yardeni D et al. Single daily dosing [[ceftriaxone]] and [[metronidazole]] vs standard triple antibiotic regimen for perforated appendicitis in children: a prospective randomized trial. J Pediatr Surg. 2008 Jun; 43(6): 981–985.</ref> | ||
Revision as of 03:40, 24 September 2019
For adult patients see appendicitis
Background
- Most common between 9-12yr
- Perforation rate 90% in children <4yr
- NPV of 98% achieved if:
- Lack of nausea (or emesis or anorexia)
- Lack of maximal TTP in the RLQ
- Lack of neutrophil count > 6750
Clinical Features
- Local tenderness + McBurney's point rigidity most reliable clinical sign
Neonates
Infants (30 days - 2 yrs)
- History
- Physical
- Diffuse abdominal tenderness
- Localized RLQ TTP occurs <50%
- Diffuse abdominal tenderness
Preschool (2 - 5yrs)
- History
- Vomiting (often precedes pain)
- Abdominal pain
- Fever
- Physical
- RLQ tenderness
School-age (6 - 12yrs)
- History
- Physical
- RLQ tenderness
Adolescents (>12yrs)
- Present similar to adults
- RLQ pain
- Vomiting (occurs after onset of abdominal pain)
- Anorexia
Differential Diagnosis
Pediatric Abdominal Pain
0–3 Months Old
- Emergent
- Nonemergent
3 mo–3 y old
- Emergent
- Nonemergent
3 y old–adolescence
- Emergent
- Nonemergent
Evaluation
Pediatric Appendicitis Score
| Nausea/vomiting | +1 |
| Anorexia | +1 |
| Migration of pain to RLQ | +1 |
| Fever | +1 |
| Cough/percussion/hopping tenderness | +2 |
| RLQ tenderness | +2 |
| Leucocytosis (WBC > 10,000) | +1 |
| Neutrophilia (ANC > 7,500) | +1 |
- Score ≤ 2
- Low risk (0-2.5%)
- Consider discharge home with close follow up
- Score 3-6
- Indeterminate risk
- Consider serial exams, consultation, or imaging
- Score ≥ 7
- High risk
- Consider surgical consultation
Laboratory Findings
- WBC
- <10K is a negative predictor of appendicitis
- Urinalysis
- 7-25% of patients with appendicitis have sterile pyuria
Imaging
Consider in intermediate or higher risk patients
- Ultrasound
- Sn: 88%, Sp: 94%
- Consider as 1st choice in non-obese children
- Indeterminate ultrasound and an Alvarado <5 has an NPV of 99.6%[1]
- CT with contrast
- Sn: 94%, Sp: 95%
- Consider if ultrasound is equivocal OR strong suspicion despite normal ultrasound
Management
- NPO
- IVF (20 mL/kg boluses)
- Analgesia
- Antibiotics
- Ampicillin/sulbactam OR cefoxitin
- Penicillin allergy?
- Gentamicin + (clindamycin OR
- metronidazole)
- Perforation or complicated appendicitis[2]
- IV antibiotic regimen as below:
- Ampicillin 100 mg/kg/d q6hr, max 8 g per dose AND
- Gentamicin 5 mg/kg QD, max 300 mg AND
- Metronidazole 30 mg/kg/d q8hr, max 1.5 g
- Daily doses of ceftriaxone and metronidazole just as effective:
- Ceftriaxone 50 mg/kg, max 2 g QD AND
- Metronidazole 30 mg/kg, max 1.5 g QD
- IV antibiotic regimen as below:
Disposition
- Admission
See Also
References
- ↑ Blitman, et al. Value of focused appendicitis ultrasound and Alverado score in predicting appendicitis in children: Can we reduce the use of CT? AJR. 2015; 204:W707-W712.
- ↑ Yardeni D et al. Single daily dosing ceftriaxone and metronidazole vs standard triple antibiotic regimen for perforated appendicitis in children: a prospective randomized trial. J Pediatr Surg. 2008 Jun; 43(6): 981–985.