Appendicitis (peds): Difference between revisions

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==Background==
==Background== <!--T:1-->


<!--T:2-->
[[File:Appendix locations.png|thumb|Drawing of colon with variability of appendix locations as seen from anterior view.]]
[[File:Appendix locations.png|thumb|Drawing of colon with variability of appendix locations as seen from anterior view.]]
*Most common between 9-12yr
*Most common between 9-12yr
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==Clinical Features==
==Clinical Features== <!--T:3-->


<!--T:4-->
[[File:McBurney's point.jpg|thumb|Location of McBurney's point (1), located two thirds the distance from the umbilicus (2) to the right anterior superior iliac spine (3).]]
[[File:McBurney's point.jpg|thumb|Location of McBurney's point (1), located two thirds the distance from the umbilicus (2) to the right anterior superior iliac spine (3).]]
*Local tenderness + McBurney's point rigidity most reliable clinical sign
*Local tenderness + McBurney's point rigidity most reliable clinical sign


===Neonates===
===Neonates=== <!--T:5-->


<!--T:6-->
*History
*History
**[[Special:MyLanguage/Nausea and vomiting (peds)|Vomiting]]
**[[Special:MyLanguage/Nausea and vomiting (peds)|Vomiting]]
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**Abdominal distention
**Abdominal distention


===Infants (30 days - 2 yrs)===
===Infants (30 days - 2 yrs)=== <!--T:7-->


<!--T:8-->
*History
*History
**[[Special:MyLanguage/Nausea and vomiting (peds)|Vomiting]]
**[[Special:MyLanguage/Nausea and vomiting (peds)|Vomiting]]
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***Localized RLQ TTP occurs <50%
***Localized RLQ TTP occurs <50%


===Preschool (2 - 5yrs)===
===Preschool (2 - 5yrs)=== <!--T:9-->


<!--T:10-->
*History
*History
**[[Special:MyLanguage/Nausea and vomiting (peds)|Vomiting]] (often precedes pain)
**[[Special:MyLanguage/Nausea and vomiting (peds)|Vomiting]] (often precedes pain)
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===School-age (6 - 12yrs)===
===School-age (6 - 12yrs)=== <!--T:11-->


<!--T:12-->
*History
*History
**[[Special:MyLanguage/Nausea and vomiting (peds)|Vomiting]]
**[[Special:MyLanguage/Nausea and vomiting (peds)|Vomiting]]
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===Adolescents (>12yrs)===
===Adolescents (>12yrs)=== <!--T:13-->


<!--T:14-->
*Present similar to adults
*Present similar to adults
**RLQ pain
**RLQ pain
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==Differential Diagnosis==
==Differential Diagnosis== <!--T:15-->


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==Evaluation==
==Evaluation== <!--T:16-->


<!--T:17-->
[[File:Appendicitis_Jarrett_Subramaniam.gif|thumbnail|Dilated, non-compressible appendix with appendicolith and surrounding free fluid<ref>http://www.thepocusatlas.com/pediatrics/</ref>]]
[[File:Appendicitis_Jarrett_Subramaniam.gif|thumbnail|Dilated, non-compressible appendix with appendicolith and surrounding free fluid<ref>http://www.thepocusatlas.com/pediatrics/</ref>]]
[[File:AppendicitisMark.png|thumb|Peri-appendiceal fat stranding in the setting of acute appendicitis.]]
[[File:AppendicitisMark.png|thumb|Peri-appendiceal fat stranding in the setting of acute appendicitis.]]
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[[File:CAT scan demonstrating acute appendicitis.jpg|thumb|Dialated appendix and stranding in the setting of acute appendicitis.]]
[[File:CAT scan demonstrating acute appendicitis.jpg|thumb|Dialated appendix and stranding in the setting of acute appendicitis.]]


===Pediatric Risk Scores===
===Pediatric Risk Scores=== <!--T:18-->




====Pediatric Appendicitis Score====
====Pediatric Appendicitis Score==== <!--T:19-->


<!--T:20-->
{| class="wikitable"
{| class="wikitable"
| Nausea/vomiting
| Nausea/vomiting
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====Pediatric Appendicitis Risk Calculator (pARC)====
====Pediatric Appendicitis Risk Calculator (pARC)==== <!--T:21-->


<!--T:22-->
*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>
*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>


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===Workup===
===Workup=== <!--T:23-->




====Laboratory Findings====
====Laboratory Findings==== <!--T:24-->


<!--T:25-->
*Abdominal panel
*Abdominal panel
**CBC
**CBC
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====Imaging====
====Imaging==== <!--T:26-->


<!--T:27-->
''Consider in intermediate or higher risk patients''
''Consider in intermediate or higher risk patients''
*[[Ultrasound: Abdomen|Ultrasound]]
*[[Ultrasound: Abdomen|Ultrasound]]
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===Diagnosis===
===Diagnosis=== <!--T:28-->


<!--T:29-->
*Patients can be ruled out via a combination of history, physical, labs, and imaging.
*Patients can be ruled out via a combination of history, physical, labs, and imaging.
*Confirmatory diagnosis is typically made on imaging
*Confirmatory diagnosis is typically made on imaging
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==Management==
==Management== <!--T:30-->




===Supportive Management===
===Supportive Management=== <!--T:31-->


<!--T:32-->
*NPO status
*NPO status
*[[Special:MyLanguage/Fluid resuscitation|Fluid resuscitation]]
*[[Special:MyLanguage/Fluid resuscitation|Fluid resuscitation]]
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===[[Special:MyLanguage/Antibiotics|Antibiotics]]===
===[[Special:MyLanguage/Antibiotics|Antibiotics]]=== <!--T:33-->


<!--T:34-->
*[[Special:MyLanguage/Ampicillin/sulbactam|Ampicillin/sulbactam]] '''OR''' [[Special:MyLanguage/cefoxitin|cefoxitin]]
*[[Special:MyLanguage/Ampicillin/sulbactam|Ampicillin/sulbactam]] '''OR''' [[Special:MyLanguage/cefoxitin|cefoxitin]]
*Penicillin allergy?
*Penicillin allergy?
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===Surgery===
===Surgery=== <!--T:35-->


<!--T:36-->
*Surgical consult, NPO, surgical pre-op labs if appropriate
*Surgical consult, NPO, surgical pre-op labs if appropriate




==Disposition==
==Disposition== <!--T:37-->


<!--T:38-->
*Admission
*Admission




==See Also==
==See Also== <!--T:39-->


<!--T:40-->
*[[Special:MyLanguage/Abdominal pain (peds)|Abdominal pain (peds)]]
*[[Special:MyLanguage/Abdominal pain (peds)|Abdominal pain (peds)]]




==References==
==References== <!--T:41-->


<!--T:42-->
<references/>
<references/>


<!--T:43-->
[[Category:Pediatrics]]
[[Category:Pediatrics]]
[[Category:Surgery]]
[[Category:Surgery]]
[[Category:ID]]
[[Category:ID]]
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Latest revision as of 17:15, 15 January 2026

Other languages:

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

Background

Drawing of colon with variability of appendix locations as seen from anterior view.
  • 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

Location of McBurney's point (1), located two thirds the distance from the umbilicus (2) to the right anterior superior iliac spine (3).
  • 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

Dilated, non-compressible appendix with appendicolith and surrounding free fluid[1]
Peri-appendiceal fat stranding in the setting of acute appendicitis.
Fecalith (arrow) and stranding in the setting of acute appendicitis.
Dialated appendix and stranding in the setting of acute appendicitis.

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
  • Consider urine pregnancy test (age appropriate)
  • Urinalysis
  • 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


Antibiotics


Surgery

  • Surgical consult, NPO, surgical pre-op labs if appropriate


Disposition

  • Admission


See Also


References

  1. ↑ http://www.thepocusatlas.com/pediatrics/
  2. ↑ 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
  3. ↑ 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.
  4. ↑ 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.
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