Appendicitis (peds)

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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 % 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

[/Abdominal-Pain-(Peds) Peds: Abdominal Pain (Peds)]

==

Source

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


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 (Peds)

Source

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

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