Appendicitis (peds): Difference between revisions

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Peds: Abdominal Pain
Peds: Abdominal Pain


== Source ==
Bundy DG et al. Does this child have appendicitis? JAMA 2007; 298:438-451, UpToDate
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== 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&nbsp;% 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
<br/>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)
<br/>See Also
Peds: Abdominal Pain (Peds)
==  ==


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


<br/>[[Category:Peds]]
<br/>[[Category:Peds]]

Revision as of 04:07, 12 March 2011

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


Source

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


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