Appendicitis (peds): Difference between revisions

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==Pearls==
{{Peds top}} [[appendicitis]]
==Background==
[[File:Appendix locations.png|thumb|Drawing of colon with variability of appendix locations as seen from anterior view.]]
*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==
[[File:McBurney's point.jpg|thumb|Location of McBurney's point (1), located two thirds the distance from the umbilicus (2) to the right anterior superior iliac spine (3).]]
*Local tenderness + McBurney's point rigidity most reliable clinical sign
===Neonates===
*History
**[[Nausea and vomiting (peds)|Vomiting]]
**Irritability/[[altered mental status (peds)|lethargy]]
*Physical
**Abdominal distention
===Infants (30 days - 2 yrs)===
*History
**[[Nausea and vomiting (peds)|Vomiting]]
**[[Abdominal pain (peds)|Abdominal pain]]
**[[Fever (Peds)|Fever]]
*Physical
**Diffuse abdominal tenderness
***Localized RLQ TTP occurs <50%
===Preschool (2 - 5yrs)===
*History
**[[Nausea and vomiting (peds)|Vomiting]] (often precedes pain)
**[[Abdominal pain (peds)|Abdominal pain]]
**[[Fever (Peds)|Fever]]
**Anorexia
*Physical
**[[RLQ tenderness]]


* Most common between 6-14 yrs (peak 9y-12y)
===School-age (6 - 12yrs)===
* Perforation rate up to 92% in children <3 yrs old
*History
* Local tenderness + rigidity at McBurney's point is most reliable clinical sign
**[[Nausea and vomiting (peds)|Vomiting]]
* Analgesia does not delay diagnosis!
**[[Abdominal pain (peds)|Abdominal pain]]
* NPV of 98% achieved if:
**[[Fever (Peds)|Fever]]
* Lack of nausea (or emesis or anorexia)
**Anorexia
* Lack of maximal TTP in the RLQ
*Physical
* Lack of neutrophil count > 6750
**RLQ tenderness
== ==


===Adolescents (>12yrs)===
*Present similar to adults
**RLQ pain
**[[Vomiting]] (occurs after onset of abdominal pain)
**Anorexia


==Diagnosis==
==Differential Diagnosis==
 
{{Pediatric abdominal pain DDX}}
 
In children with abdominal pain:
 
Sx +LR -LR
Fever 3.4
Rebound 3.0 0.28
Migration 2.5 1.2
WBC <10k 0.22
ANC <6,750 0.06
== ==
 
 
==History & Physical==
 
 
* Neonates (birth - 30 days)
* 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
== ==
 
 
==Laboratory Findings==
 


* WBC or neutrophil % elevation
==Evaluation==
* Sn/Sp = 79/80%
[[File:Appendicitis_Jarrett_Subramaniam.gif|thumbnail|Dilated, non-compressible appendix with appendicolith and surrounding free fluid<ref>http://www.thepocusatlas.com/pediatrics/</ref>]]
* May also be seen in gastroenteritis, strep, PNA, PID
[[File:AppendicitisMark.png|thumb|Peri-appendiceal fat stranding in the setting of acute appendicitis.]]
* CRP
[[File:X-ray showing fecalith which has caused appendicitis.jpg|thumb|Fecalith (arrow) and stranding in the setting of acute appendicitis.]]
* May be more Sn than WBC in identifying perforation
[[File:CAT scan demonstrating acute appendicitis.jpg|thumb|Dialated appendix and stranding in the setting of acute appendicitis.]]
* Consider in pts with a prolonged history
===Pediatric Risk Scores===
* UA
====Pediatric Appendicitis Score====
* 7-25% of pts with appy have sterile pyuria
{| class="wikitable"
| 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


==Imaging==
====Pediatric Appendicitis Risk Calculator (pARC)====
*pARC score shown to outperform Pediatric Appendicitis Score. pARC score accurately assesses risk of appendicitis in children age 5 years and older in community EDs <ref>Cotton D, et al., Validation of the Pediatric Appendicitis Risk Calculator (pARC) in a Community Emergency Department Setting. Annals Emrg. Med. 2019; 74(4) 471-480</ref>


{{Alvarado scoring system}}


* Consider only in intermediate-risk pts
===Workup===
* Ultrasound
====Laboratory Findings====
* Sn: 88%, Sp: 94%
*Abdominal panel
* Consider as 1st choice in non-obese children
**CBC
* CT (+/- contrast)
***<10K is a negative predictor of appendicitis
* Sn: 94%, Sp: 95%
***However, normal WBC does not rule-out appendicitis
* Consider if U/S is equivocal OR strong suspicion despite normal U/S 
**Chemistry
**Consider LFTs + lipase
**Consider coagulation studies (PT, PTT, INR), as a marker of liver function
*Consider urine pregnancy test (age appropriate)
*[[Urinalysis]]
**7-25% of patients with appendicitis have [[sterile pyuria]]
*Consider [[serum lactate]]


Pediatric Appendicitis Score
====Imaging====
''Consider in intermediate or higher risk patients''
*[[Ultrasound: Abdomen|Ultrasound]]
**Sn: 88%, Sp: 94%
**Consider as 1st choice in non-obese children
**Indeterminate [[ultrasound]] and an Alvarado <5 (see below) has an NPV of 99.6%<ref>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.</ref>
*CT with IV contrast
**Sn: 94%, Sp: 95%
**Consider if ultrasound is equivocal '''OR''' strong suspicion despite normal ultrasound


* Anorexia - 1pt
===Diagnosis===
* Nausea or vomiting - 1pt
*Patients can be ruled out via a combination of history, physical, labs, and imaging.
* Migration of pain - 1pt
*Confirmatory diagnosis is typically made on imaging
* Fever > 100.5 - 1pt
*Ultrasound is typically performed first:
* Pain with cough, percussion, or hopping - 2pt
**If appendix is positive, appendicitis is ruled in
* RLQ tenderness - 2pt
**If appendix is visualized and negative, appendicitis is ruled out
* WBC > 10K - 1pt
**If appendix is unable to be visualized (i.e., indeterminant), then post-test probability is unchanged. Re-examine and consider CT as next diagnostic study.
* Neutrophils + bands > 7500- 1pt
* Score ≤ 2
* Low risk (0-2.5%)
* Consider d/c home with close f/u
* Score ≥ 7
* High risk
* Consider surgical consultation
* Score 3-6
* Indeterminate risk
* Consider serial exams, consultation, or imaging


==Management==
==Management==
===Supportive Management===
*NPO status
*[[Fluid resuscitation]]
**[[IVF]] (20 mL/kg boluses)
*[[Analgesia]]/[[antiemetics]] (e.g., [[morphine]], [[ondansetron]])


===[[Antibiotics]]===
*[[Ampicillin/sulbactam]] '''OR''' [[cefoxitin]]
*Penicillin allergy?
**[[Gentamicin]] + ([[clindamycin]] '''OR'''
**[[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>
**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


* Fluids (20 mL/kg boluses)
===Surgery===
* Analgesia
*Surgical consult, NPO, surgical pre-op labs if appropriate
* ABx
* Second gen cephalosporin OR
* Piperacillin/tazobactam OR
* Penicillin allergy?
* Gent + (clinda or metronidazole) 
 
==Differential Diagnosis==
 
 
* Emergent surgical diagnoses
* Bowel obstruction
* Malrotation
* Intussusception
* Ovarian torsion
* Ectopic pregnancy
* Emergent nonsurgical diagnoses
* HUS
* DKA
* Non-emergent diagnoses
* PID
* PNA
* UTI
* Strep throat
* Gastroenteritis (esp yersinia)
 
See Also
 
Peds:  Abdominal Pain (Peds)
 
== ==
 
 
==Source==
 
 
Bundy DG et al. Does this child have appendicitis? JAMA 2007; 298:438-451, UpToDate


==Disposition==
*Admission


==See Also==
*[[Abdominal pain (peds)]]


==References==
<references/>


[[Category:Peds]]
[[Category:Pediatrics]]
[[Category:Surgery]]
[[Category:ID]]

Latest revision as of 21:49, 14 February 2024

This page is for pediatric patients. For adult patients, see: appendicitis

Background

Drawing of colon with variability of appendix locations as seen from anterior view.
  • 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

Location of McBurney's point (1), located two thirds the distance from the umbilicus (2) to the right anterior superior iliac spine (3).
  • Local tenderness + McBurney's point rigidity most reliable clinical sign

Neonates

Infants (30 days - 2 yrs)

Preschool (2 - 5yrs)

School-age (6 - 12yrs)

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

3 mo–3 y old

3 y old–adolescence

Evaluation

Dilated, non-compressible appendix with appendicolith and surrounding free fluid[1]
Peri-appendiceal fat stranding in the setting of acute appendicitis.
Fecalith (arrow) and stranding in the setting of acute appendicitis.
Dialated appendix and stranding in the setting of acute appendicitis.

Pediatric Risk Scores

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

Pediatric Appendicitis Risk Calculator (pARC)

  • pARC score shown to outperform Pediatric Appendicitis Score. pARC score accurately assesses risk of appendicitis in children age 5 years and older in community EDs [2]

Alvarado Clinical Scoring System

Right Lower Quadrant Tenderness +2
Elevated Temperature (37.3°C or 99.1°F) +1
Rebound Tenderness +1
Migration of Pain to the Right Lower Quadrant +1
Anorexia +1
Nausea or Vomiting +1
Leukocytosis > 10,000 +2
Leukocyte Left Shift +1

Clinical scoring system, where a score (Total=10) is composed on presence/absence of 3 signs, 3 symptoms and 2 lab values to help guide in case management.

  • ≤3 = Appendicitis unlikely
  • ≥7 = Surgical consultation
  • 4-6 = Consider CT

MANTRELS Mnemonic: Migration to the right iliac fossa, Anorexia, Nausea/Vomiting, Tenderness in the right iliac fossa, Rebound pain, Elevated temperature (fever), Leukocytosis, and Shift of leukocytes to the left (factors listed in the same order as presented above).

Workup

Laboratory Findings

  • Abdominal panel
    • CBC
      • <10K is a negative predictor of appendicitis
      • However, normal WBC does not rule-out appendicitis
    • Chemistry
    • Consider LFTs + lipase
    • Consider coagulation studies (PT, PTT, INR), as a marker of liver function
  • Consider urine pregnancy test (age appropriate)
  • Urinalysis
  • Consider serum lactate

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 (see below) has an NPV of 99.6%[3]
  • CT with IV contrast
    • Sn: 94%, Sp: 95%
    • Consider if ultrasound is equivocal OR strong suspicion despite normal ultrasound

Diagnosis

  • Patients can be ruled out via a combination of history, physical, labs, and imaging.
  • Confirmatory diagnosis is typically made on imaging
  • Ultrasound is typically performed first:
    • If appendix is positive, appendicitis is ruled in
    • If appendix is visualized and negative, appendicitis is ruled out
    • If appendix is unable to be visualized (i.e., indeterminant), then post-test probability is unchanged. Re-examine and consider CT as next diagnostic study.

Management

Supportive Management

Antibiotics

Surgery

  • Surgical consult, NPO, surgical pre-op labs if appropriate

Disposition

  • Admission

See Also

References

  1. ↑ http://www.thepocusatlas.com/pediatrics/
  2. ↑ Cotton D, et al., Validation of the Pediatric Appendicitis Risk Calculator (pARC) in a Community Emergency Department Setting. Annals Emrg. Med. 2019; 74(4) 471-480
  3. ↑ 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.
  4. ↑ 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.
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