Appendicitis (peds): Difference between revisions

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== Background ==
{{Peds top}} [[appendicitis]]
 
==Background==
*Most common between 9-12yr
*Most common between 9-12yr
*Perforation rate 90% in children <4yr
*Perforation rate 90% in children <4yr
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**Lack of neutrophil count > 6750
**Lack of neutrophil count > 6750


== Diagnosis ==
==Clinical Features==
*Local tenderness + McBurney's point rigidity most reliable clinical sign
*Local tenderness + McBurney's point rigidity most reliable clinical sign
===Neonates===
===Neonates===
*History
*History
**Vomiting
**[[Nausea and vomiting (peds)|Vomiting]]
**Irritability/lethargy
**Irritability/[[altered mental status (peds)|lethargy]]
*Physical
*Physical
**Abdominal distention
**Abdominal distention
===Infants (30 days - 2 yrs)===
===Infants (30 days - 2 yrs)===
*History
*History
**Vomiting
**[[Nausea and vomiting (peds)|Vomiting]]
**Abdominal pain
**[[Abdominal pain (peds)|Abdominal pain]]
**Fever
**[[Fever (Peds)|Fever]]
*Physical
*Physical
**Diffuse abdominal tenderness
**Diffuse abdominal tenderness
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===Preschool (2 - 5yrs)===
===Preschool (2 - 5yrs)===
*History
*History
**Vomiting (often precedes pain)
**[[Nausea and vomiting (peds)|Vomiting]] (often precedes pain)
**Abdominal pain
**[[Abdominal pain (peds)|Abdominal pain]]
**Fever
**[[Fever (Peds)|Fever]]
*Physical
*Physical
**RLQ tenderness
**RLQ tenderness
===School-age (6 - 12yrs)===
===School-age (6 - 12yrs)===
*History
*History
**Vomiting
**[[Nausea and vomiting (peds)|Vomiting]]
**Abdominal pain
**[[Abdominal pain (peds)|Abdominal pain]]
**Fever
**[[Fever (Peds)|Fever]]
*Physical
*Physical
**RLQ tenderness
**RLQ tenderness
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*Present similar to adults
*Present similar to adults
**RLQ pain
**RLQ pain
**Vomiting (occurs after onset of abdominal pain)
**[[Vomiting]] (occurs after onset of abdominal pain)
**Anorexia
**Anorexia


== Laboratory Findings ==
==Differential Diagnosis==
*WBC
{{Pediatric abdominal pain DDX}}
**<10K is strong negative predictor for appy
*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


==Evaluation==


===Pediatric Appendicitis Score===
{| 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
*Score ≤ 2
**Low risk (0-2.5%)
**Low risk (0-2.5%)
**Consider d/c home with close f/u
**Consider discharge home with close follow up
*Score 3-6
**Indeterminate risk
**Consider serial exams, consultation, or imaging
*Score ≥ 7
*Score ≥ 7
**High risk
**High risk
**Consider surgical consultation
**Consider surgical consultation
*Score 3-6
**Indeterminate risk
**Consider serial exams, consultation, or imaging


== Management ==
===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>
 
===Laboratory Findings===
*WBC
**<10K is a negative predictor of appendicitis
*[[Urinalysis]]
**7-25% of patients with appendicitis have sterile pyuria
 
===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 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 contrast
**Sn: 94%, Sp: 95%
**Consider if ultrasound is equivocal '''OR''' strong suspicion despite normal ultrasound
 
==Management==
*NPO
*NPO
*IVF (20 mL/kg boluses)
*[[IVF]] (20 mL/kg boluses)
*Analgesia
*[[Analgesia]]
*ABx
**[[Ketorolac]]
**Ampicillin/sulbactam OR
**[[Morphine]]
**Cefoxitin
*[[Antibiotics]]
**[[Ampicillin/sulbactam]] '''OR''' [[cefoxitin]]
**Penicillin allergy?
**Penicillin allergy?
***Gent + (clinda or metronidazole)
***[[Gentamicin]] + ([[clindamycin]] '''OR'''
**Perforation?
***[[metronidazole]])
***Piperacillin/tazobactam
**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
 
==Disposition==
*Admission


==See Also==
==See Also==
[[Abdominal Pain (Peds)]]
*[[Abdominal pain (peds)]]
 
== Source ==
UpToDate, Tintinalli


[[Category:Peds]]
==References==
<references/>


[[Category:GI]]
[[Category:Pediatrics]]
[[Category:Surgery]]
[[Category:ID]]

Revision as of 22:49, 28 November 2019

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

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

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

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 [1]

Laboratory Findings

  • WBC
    • <10K is a negative predictor of appendicitis
  • Urinalysis
    • 7-25% of patients with appendicitis have sterile pyuria

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 has an NPV of 99.6%[2]
  • CT with contrast
    • Sn: 94%, Sp: 95%
    • Consider if ultrasound is equivocal OR strong suspicion despite normal ultrasound

Management

Disposition

  • Admission

See Also

References

  1. 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
  2. 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.
  3. 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.