Appendicitis (peds)

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

  • 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

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

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%[1]
  • 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. 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.
  2. 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.