Appendicitis (peds)

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)

See Also

Peds: Abdominal Pain (Peds)

Source

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