Appendicitis (peds): Difference between revisions

Revision as of 23:38, 1 March 2011

Pearls

Most common between 6-14 yrs (peak 9y-12y)
Perforation rate up to 92% in children <3 yrs old
Local tenderness + rigidity at McBurney's point is most reliable clinical sign
Analgesia does not delay diagnosis!
NPV of 98% achieved if:
Lack of nausea (or emesis or anorexia)
Lack of maximal TTP in the RLQ
Lack of neutrophil count > 6750

Diagnosis

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
Sn/Sp = 79/80%
May also be seen in gastroenteritis, strep, PNA, PID
CRP
May be more Sn than WBC in identifying perforation
Consider in pts with a prolonged history
UA
7-25% of pts with appy have sterile pyuria

Imaging

Consider only in intermediate-risk pts
Ultrasound
Sn: 88%, Sp: 94%
Consider as 1st choice in non-obese children
CT (+/- contrast)
Sn: 94%, Sp: 95%
Consider if U/S is equivocal OR strong suspicion despite normal U/S

Pediatric Appendicitis Score

Anorexia - 1pt
Nausea or vomiting - 1pt
Migration of pain - 1pt
Fever > 100.5 - 1pt
Pain with cough, percussion, or hopping - 2pt
RLQ tenderness - 2pt
WBC > 10K - 1pt
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

Fluids (20 mL/kg boluses)
Analgesia
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)

Source

Bundy DG et al. Does this child have appendicitis? JAMA 2007; 298:438-451, UpToDate

Authors:

@@ Line 1: / Line 1: @@
-==Background==
+==Pearls==
-* most common between 6-14 yrs (peak 9y-12y), 6% of pop., d/t lumen of appy obst= inflamm= later perf, perf rate up to 92% in children <3 yrs old!
+* Most common between 6-14 yrs (peak 9y-12y)
+* Perforation rate up to 92% in children <3 yrs old
+* Local tenderness + rigidity at McBurney's point is most reliable clinical sign
+* Analgesia does not delay diagnosis!
+* NPV of 98% achieved if:
+* Lack of nausea (or emesis or anorexia)
+* Lack of maximal TTP in the RLQ
+* Lack of neutrophil count > 6750
 == ==
@@ Line 8: / Line 15: @@
 ==Diagnosis==
-Likelihood Ratios
 In children with abdominal pain:
@@ Line 22: / Line 27: @@
-S/S in children <2 can be vague (vomiting 85-90%, pain 35-77%, diarrhea 18-46%, fever 40-60%, irritability, refusal to walk, limp, inc resp rate, grunting, anorexia is seen in 50% of >12 y/o, 20% will have nl WBC, UA may hve some RBC/WBC usu not too high
+==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
+* Sn/Sp = 79/80%
+* May also be seen in gastroenteritis, strep, PNA, PID
+* CRP
+* May be more Sn than WBC in identifying perforation
+* Consider in pts with a prolonged history
+* UA
+* 7-25% of pts with appy have sterile pyuria
-reynolds 'peds emergcare 1992' found 97% of pts w/ appy had 2/4-prosp eval of 377 children age 2-16, appendicitis in 8%, 97% of pts (2y-16y) with appy had 2/4 of vomiting, guarding, TTP, RLQ pain, 28% w/o appy had these. (PPV=24% NPV=99%)
+==Imaging==
-== ==
+* Consider only in intermediate-risk pts
+* Ultrasound
+* Sn: 88%, Sp: 94%
+* Consider as 1st choice in non-obese children
+* CT (+/- contrast)
+* Sn: 94%, Sp: 95%
+* Consider if U/S is equivocal OR strong suspicion despite normal U/S
+Pediatric Appendicitis Score
+* Anorexia - 1pt
+* Nausea or vomiting - 1pt
+* Migration of pain - 1pt
+* Fever > 100.5 - 1pt
+* Pain with cough, percussion, or hopping - 2pt
+* RLQ tenderness - 2pt
+* WBC > 10K - 1pt
+* 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==
+* Fluids (20 mL/kg boluses)
+* Analgesia
+* ABx
+* Second gen cephalosporin OR
+* Piperacillin/tazobactam OR
+* Penicillin allergy?
+* Gent + (clinda or metronidazole)
+==Differential Diagnosis==
-==See Also==
+* 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)
@@ Line 42: / Line 154: @@
-Bundy DG et al. Does this child have appendicitis? JAMA 2007; 298:438-451
+Bundy DG et al. Does this child have appendicitis? JAMA 2007; 298:438-451, UpToDate