Appendicitis (peds): Difference between revisions
Ostermayer (talk | contribs) (Text replacement - " pts" to " patients") |
Neil.m.young (talk | contribs) (Text replacement - "== " to "==") |
||
| Line 1: | Line 1: | ||
== Background == | ==Background == | ||
*Most common between 9-12yr | *Most common between 9-12yr | ||
| Line 8: | Line 8: | ||
**Lack of neutrophil count > 6750 | **Lack of neutrophil count > 6750 | ||
== Clinical Features== | ==Clinical Features== | ||
*Local tenderness + McBurney's point rigidity most reliable clinical sign | *Local tenderness + McBurney's point rigidity most reliable clinical sign | ||
===Neonates=== | ===Neonates=== | ||
| Line 88: | Line 88: | ||
**Consider surgical consultation | **Consider surgical consultation | ||
=== Laboratory Findings === | ===Laboratory Findings === | ||
*WBC | *WBC | ||
**<10K is strong negative predictor for appy | **<10K is strong negative predictor for appy | ||
| Line 94: | Line 94: | ||
**7-25% of patients with appy have sterile pyuria | **7-25% of patients with appy have sterile pyuria | ||
=== Imaging === | ===Imaging === | ||
*Consider only in intermediate-risk patients | *Consider only in intermediate-risk patients | ||
*[[Ultrasound: Abdomen|Ultrasound]] | *[[Ultrasound: Abdomen|Ultrasound]] | ||
| Line 104: | Line 104: | ||
**Consider if U/S is equivocal OR strong suspicion despite normal U/S | **Consider if U/S is equivocal OR strong suspicion despite normal U/S | ||
== Management == | ==Management == | ||
*NPO | *NPO | ||
*[[IVF]] (20 mL/kg boluses) | *[[IVF]] (20 mL/kg boluses) | ||
Revision as of 12:43, 5 July 2016
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
- History
- Vomiting
- Irritability/lethargy
- Physical
- Abdominal distention
Infants (30 days - 2 yrs)
- History
- Vomiting
- Abdominal pain
- Fever
- 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
- Vomiting
- Abdominal pain
- Fever
- 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
Diagnosis
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 |
- Low Risk < 4
- High Risk ≥ 7
- Score ≤ 2
- Low risk (0-2.5%)
- Consider discharge home with close f/u
- Score 3-6
- Indeterminate risk
- Consider serial exams, consultation, or imaging
- Score ≥ 7
- High risk
- Consider surgical consultation
Laboratory Findings
- WBC
- <10K is strong negative predictor for appy
- UA
- 7-25% of patients with appy have sterile pyuria
Imaging
- Consider only in intermediate-risk patients
- Ultrasound
- Sn: 88%, Sp: 94%
- Consider as 1st choice in non-obese children
- Indeterminate US and an Alvarado <5 has an NPV of 99.6%[1]
- CT (+/- contrast)
- Sn: 94%, Sp: 95%
- Consider if U/S is equivocal OR strong suspicion despite normal U/S
Management
- NPO
- IVF (20 mL/kg boluses)
- Analgesia
- Antibiotics
- Ampicillin/sulbactam OR cefoxitin
- Penicillin allergy?
- Gentamycin + (clindamycin or metronidazole)
- Perforation?
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.