Appendicitis (peds)
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)
- History
- Physical
- Diffuse abdominal tenderness
- Localized RLQ TTP occurs <50%
- Diffuse abdominal tenderness
Preschool (2 - 5yrs)
- History
- Vomiting (often precedes pain)
- Abdominal pain
- Fever
- Anorexia
- Physical
School-age (6 - 12yrs)
- History
- Vomiting
- Abdominal pain
- Fever
- Anorexia
- 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
- Nonemergent
3 mo–3 y old
- Emergent
- Nonemergent
3 y old–adolescence
- Emergent
- Nonemergent
Evaluation
Dilated, non-compressible appendix with appendicolith and surrounding free fluid[1]
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
- CBC
- Consider urine pregnancy test (age appropriate)
- Urinalysis
- 7-25% of patients with appendicitis have sterile pyuria
- 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
- 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[4]
- 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
- IV antibiotic regimen as below:
Surgery
- Surgical consult, NPO, surgical pre-op labs if appropriate
Disposition
- Admission
See Also
References
- ↑ http://www.thepocusatlas.com/pediatrics/
- ↑ 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
- ↑ 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.
- ↑ 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.