Appendicitis (peds)

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%

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
  • Necrotizing Enterocolitis
  • Volvulus
  • Testicular torsion
  • Inguinal hernia
    • Incarcerated hernia
  • Trauma
  • Pyloric stenosis
  • Toxic megacolon
  • Hirschsprung's Disease
• Nonemergent
  • Constipation
  • Acute Gastroenteritis
  • Colic

3 mo–3 y old

• Emergent
  • Intussusception
  • Testicular Torsion
  • Trauma
  • Volvulus
  • Appendicitis
  • Toxic megacolon
  • Vaso-occlusive crisis
• Nonemergent
  • Acute Gastroenteritis
  • Constipation
  • Urinary tract infection
  • Henoch-Schonlein purpura

3 y old–adolescence

• Emergent
  • Appendicitis
  • DKA
  • Vaso-occlusive crisis
  • Toxic ingestion
  • Testicular Torsion
  • Ovarian Torsion
  • Ectopic Pregnancy
  • Trauma
  • Toxic megacolon
  • Inflammatory bowel disease
  • Gastric ulcer disease
  • Ovarian cyst
  • Pregnancy
  • Pancreatitis
  • Cholecystitis
  • Intussusception (to age 6)
• Nonemergent
  • Constipation
  • Acute Gastroenteritis
  • Nonspecific viral syndrome
  • Streptococcus pharyngitis
  • Urinary tract infection
  • Pneumonia
  • Renal Stone
  • Henoch-Schonlein purpura
  • Inflammatory bowel disease
  • Vulvovaginitis

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 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 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%
• 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
  • Ketorolac
  • Morphine
• Antibiotics
  • Ampicillin/sulbactam OR cefoxitin
  • Penicillin allergy?
    • Gentamycin + (clindamycin or metronidazole)
  • Perforation?
    • Piperacillin/tazobactam

Disposition

• Admission

See Also

• Abdominal Pain (Peds)