eMedicine - Pediatrics, Appendicitis : Article by Jerome FX Naradzay, MD, FACEP

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Pediatrics, Appendicitis

Last Updated: November 15, 2006

Synonyms and related keywords: appendicitis in children, acute inflammation of the appendix, abdominal pain, appendix, acute appendicitis, appendiceal inflammation

AUTHOR INFORMATION Section 1 of 10

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Author: Jerome FX Naradzay, MD, FACEP, Emergency Services Medical Director, Department of Emergency Medicine, Maria Parham Medical Center
Coauthor(s): Jeffrey Tucker, MD, Assistant Professor, Department of Pediatrics, Division of Emergency Medicine, University of Connecticut and Connecticut Children's Medical Center

Jerome FX Naradzay, MD, FACEP, is a member of the following medical societies: American College of Emergency Physicians, and Society for Academic Emergency Medicine

Editor(s): Kirsten Bechtel, MD, Assistant Professor, Department of Pediatrics, Division of Pediatric Emergency Medicine, Yale-New Haven Children's Hospital; Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine.com, Inc; Wayne Wolfram, MD, MPH, Clinical Associate Professor, Departments of Pediatrics, Children's Hospital and University of Cincinnati; John Halamka, MD, Chief Information Officer, CareGroup Healthcare System, Assistant Professor of Medicine, Department of Emergency Medicine, Beth Israel Deaconess Medical Center; Assistant Professor of Medicine, Harvard Medical School; and Richard G Bachur, MD, Assistant Professor of Pediatrics, Harvard Medical School; Associate Chief and Fellowship Director, Division of Emergency Medicine, Children's Hospital of Boston

Disclosure

INTRODUCTION

Section 2 of 10

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Background: A very common and widely known disease is appendicitis, a condition whereby the appendix becomes inflamed and swollen. Symptoms of appendicitis include abdominal pain, fever, and vomiting. It is one of the top three conditions leading to pediatric abdominal surgery.

The appendix looks like a hollow, fleshy stalk arising from the cecum near the ileocecal junction.

To help understand what happens during appendicitis, the appendix can be described as a blind pouch, hollow stalk, or diverticulum that becomes swollen, inflamed, infected, or ruptured.

While the base of the appendix is fixed to the cecum, the tip of the appendix can be located retrocecally, pelvically, or extraperitoneally. The appendix is usually 1-3 inches in length. The longest appendix documented was more than 9 inches in length. Commonly, the appendix is located at the lower right quadrant of the abdomen, approximately a hand's width above the inguinal crease. In people with situs inversus, the appendix may be located in the lower left side.

Although it may not have a function, for many years, investigators have proffered several appendiceal activities: lymphatic, exocrine, endocrine, and neuromuscular functions.

An operation to remove the appendix is an appendectomy or an appendicectomy.

Appendicitis and carcinoid are two common diseases that afflict the appendix.

Pathophysiology: Appendicitis begins when the lumen, or hollow center, becomes blocked. Conditions or items that have been associated with blockage include stool, barium, food, or parasites. Sometimes, the lumen becomes blocked because surrounding appendiceal tissue, which is rich in lymph glands, becomes swollen with hyperplastic lymphoid tissue.

Once the appendiceal lumen is blocked, the appendiceal mucosal becomes edematous. A vicious cycle begins where intraluminal pressure increases, inflammation ensues, and exudate drains from the appendix. Wherever the exudate touches the parietal peritoneum, the patient experiences pain. Fecal bacteria grow within the obstructing material, thereby enhancing the inflammatory response and further increasing the intraluminal pressure.

If the diagnosis of appendicitis is not made early, the obstruction progresses, the wall of the appendix stretches due to the further rise in intraluminal pressure, and perforation occurs. When the inflammatory fluid and bacterial contents are released into the abdominal cavity, peritonitis develops. Concomitantly, the patient complains of more intense and generalized abdominal pain.

In adults and adolescents, the omentum can wall off the inflamed or perforated appendix, causing a focal abscess. In the younger child, the omentum is less well developed and less likely to wall off a perforation, making peritonitis more likely.

Children and adults have also developed appendicitis following severe blunt abdominal trauma.

Two types of appendicitis may exist. In one type, Th2 immunity, appendiceal inflammation may resolve spontaneously. In contrast, individuals with Th1 immunity, advances to gangrene and perforation. Individuals with a history of gangrenous appendicitis demonstrated ability to increased interleukin 10 (IL-10) and interferon-gamma (IFN-gamma) production. The increased IFN-gamma may reflect an uncontrolled Th1-mediated inflammatory response leading to gangrene. Increased IL-10 may indicate the role of cytotoxic cells leading progression to perforation.

Frequency:

In the US: GI disorders, including appendicitis, were the third leading cause of pediatric hospitalization.
Appendicitis occurs in all age groups but is rare in infants. The incidence in the United States is 4 cases per 1000 children.

Mortality/Morbidity:

At the time of diagnosis, the rate of perforation varies from 17-40%, with a higher frequency occurring in younger age groups.

The mortality rate for children with appendicitis ranges from 0.1-1%.

Perforation increases the complication rate.

Race: The role of race, ethnicity, health insurance, education, access to healthcare, and economic status on the development and treatment of appendicitis are widely debated. Cogent arguments have been made on both sides for and against the significance of each socioeconomic or racial condition.

Sex: The male-to-female ratio is approximately 2:1.

Age: Appendicitis occurs in all age groups. However, children younger than 6 years typically present for treatment with more advanced appendicitis. It can be stated that the younger the child, the more advanced the appendicitis. Almost universally, a child who is younger than 1-2 years is likely to have a perforated appendix by the time the diagnosis is made.

The mean age in the pediatric population is 6-10 years.

Appendicitis is rare in the neonate, and the diagnosis in this age group is typically made after perforation.

Younger children have a higher rate of perforation, with reported rates of 50-85%.

CLINICAL

Section 3 of 10

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History: Understanding the typical clinical manifestations of appendicitis is important in order to make an early and accurate diagnosis prior to perforation. The classic history of anorexia and periumbilical pain, followed by right lower quadrant (RLQ) pain and vomiting, is observed in fewer than 60% of patients. The clinician is more likely to make the diagnosis by maintaining a high degree of suspicion, a broad differential diagnosis, and looking for the atypical case rather than the classic appendicitis (1-2 d of fever, vomiting, right lower quadrant pain, anorexia).

Vomiting, RLQ pain, tenderness, and guarding are significantly (all P less than 0.001) associated with appendicitis.

The initial symptom is poorly defined periumbilical pain, often associated with anorexia.

Acute onset of severe pain is typically present with acute ischemic conditions, such as volvulus, testicular torsion, ovarian torsion, or intussusception.

In appendicitis, nausea and vomiting develop shortly after onset of pain.

In most cases of appendicitis, abdominal pain precedes vomiting.

After a few hours, the pain shifts to the RLQ due to inflammation of the parietal peritoneum.

This pain is more intense, continuous, and more localized than the initial pain.

This shift of pain rarely occurs in other abdominal conditions.

Most children with appendicitis either are afebrile or have a low-grade fever.

High fever is not a common presenting feature unless perforation has occurred.

Vomiting and fever are more frequent in children with appendicitis than in children with other causes of abdominal pain.

A careful family history should be obtained for every child in whom acute appendicitis is suspected.

Multiple studies have demonstrated that children who have appendicitis are more than likely to have a positive family history.

To date, not enough evidence exists to support a major gene for appendicitis. Nonetheless, a positive family history of appendicitis must be appreciated and respected when evaluating a child with abdominal pain.

Evaluation rules and algorithms have been proposed to help the clinician make the correct diagnosis and treatment plan. Nothing in emergency medicine is guaranteed, but decision rules can predict which children are at low risk for appendicitis.

One such numerically based system is based on a 6-part scoring system: nausea (2 points), history of focal RLQ pain (2 points), migration of pain (1 point), difficulty walking (1 point), rebound tenderness/pain with percussion (2 points), and absolute neutrophil count of >6.75 X 10³/mL (6 points).

A score < 5 had a sensitivity of 96.3% (95% confidence interval [CI], 87.5-99.0), a negative predictive value of 95.6% (95% CI, 90.8-99.0), and a negative likelihood ratio of 0.102 (95% CI, 0.026-0.405) in the validation set.

The keys to any evaluation and treatment plan that involve equivocal history, physical examination findings, and inconclusive supporting test results include relieving the patient's pain and discomfort early and often, communicating with the patient and family about the plans, discovering and addressing concerns, repeating the examination often, adjusting the differential diagnosis, and keeping the patient for observation if a firm diagnosis is not made or for follow-up. Algorithms, scoring systems, imaging studies, and consultation reports are part of the clinician's armamentarium. Always document what actions were taken or why actions were not taken in a particular way. Let the record reflect the thought process and support for the thought process with reports such as algorithms and scoring systems.

Physical: Children vary in their ability to cooperate with the physical examination. It is important to tailor the physical examination with respect to the child's age and developmental stage. It is important to exclude extra-abdominal causes of abdominal pain.

Observation of the child's interaction and gait prior to the examination can be extremely helpful.

A child with appendicitis typically prefers to lie still due to peritoneal irritation.

Observing the child's facial expression during palpation of the abdomen can be helpful in eliciting the location and intensity of any abdominal pain.

Localization of the pain depends on the position of the appendix.

Typically, maximal tenderness can be found at McBurney point in the right lower quadrant.

Rovsing sign is pain in the RLQ in response to left-sided palpation and strongly suggests peritoneal irritation

The psoas sign is determined by placing the child on the left side and hyperextending the right leg.

The obturator sign is determined by internal rotation of the flexed right thigh. Pain on movement may be caused by an inflammatory mass overlying the psoas muscle.

The cough sign (sharp pain in the RLQ after a voluntary cough) is suggestive of peritoneal irritation.

A rectal examination should be performed last and may reveal impacted stool, right-sided tenderness, or a mass. Be sure to perform a rectal examination (inspection, palpation, and digital examination) in children who have any abdominal tenderness, a history of constipation, a history of rectal bleeding, trauma, or suspected physical abuse.

Causes: Most causes of appendiceal inflammation, infection, and perforation begin with something obstructing the appendiceal lumen. Items such as stool, barium, food, and parasites can block the lumen. Malignant tissue such as that caused by carcinoid, leukemia, and lymphoma can cause tissue swelling and lumen obstruction.

Blunt abdominal trauma has been identified as a cause for appendicitis.

DIFFERENTIALS Section 4 of 10

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Ovarian Cysts
Ovarian Torsion
Pancreatitis
Pediatrics, Diabetic Ketoacidosis
Pediatrics, Gastroenteritis
Pediatrics, Henoch-Schönlein Purpura
Pediatrics, Intussusception
Pediatrics, Pneumonia
Pediatrics, Sickle Cell Disease
Pediatrics, Urinary Tract Infections and Pyelonephritis
Pelvic Inflammatory Disease
Pregnancy, Ectopic
Renal Calculi
Testicular Torsion

Other Problems to be Considered:

Lymphoma
Leukemia
Neurogenic appendicopathy
Paratubal cysts
Intentional injury
Sexual abuse
Typhilitis

Quick Find

Author Information
Introduction
Clinical
Differentials
Workup
Treatment
Medication
Follow-up
Miscellaneous
Bibliography

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Pediatrics, Sickle Cell Disease

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WORKUP

Section 5 of 10

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Lab Studies:

Laboratory findings may increase the suspicion for appendicitis but are not diagnostic.

A minimum laboratory evaluation for patients with possible appendicitis includes a CBC with differential and urinalysis.

The WBC count is elevated in approximately 70-90% of patients with acute appendicitis but also is elevated in many other abdominal conditions.

The predictive value of the WBC count is limited. Because at least 10% of patients with appendicitis have a WBC count within the reference range, appendicitis cannot be excluded based on a WBC count within the reference range. It is important to interpret the WBC count with respect to the clinical presentation.

If the WBC count exceeds 15,000 cells/mm³, the patient is more likely to have a perforation. However, one study found no difference in the WBC count between children with simple appendicitis and those with a perforated appendicitis.

Urinalysis is useful for detecting urinary tract disease, such as infection or renal stones.

Irritation of the bladder or ureter by an inflamed appendix may result in a few WBCs in the urine, but the presence of over 20 WBCs/hpf suggests a urinary tract infection.

Causes of hematuria include renal stones, urinary tract infection, Henoch-Schönlein purpura (HSP), or hemolytic uremic syndrome (HUS).

Normal findings on urinalysis are of limited diagnostic value for appendicitis. Grossly abnormal urinalysis findings may suggest another cause of abdominal pain.

Electrolytes and renal function tests are more helpful in the management than in the diagnosis of appendicitis. Indications for assessing electrolytes include a significant history of vomiting or clinical suspicion of dehydration.

Triple test - C-reactive protein (CRP), total white blood cell count (WBC), and neutrophil percentage

Positive triple test - CRP values of more than (8 mcg/mL), and total WBC count of more than (11,000/mL), and neutrophil percentage of more than 75%.

The sensitivity, specificity, positive predictive value, and negative predictive values of the 3 tests in combination were 86%, 90.7%, 93%, 81.2%, respectively.

Liver function tests, serum amylase, and serum lipase may be helpful when the etiology of the abdominal pain is unclear.

Urinary levels of human chorionic gonadotropin-beta subunit (hCG-beta) are useful in sexually active adolescent females to exclude ectopic pregnancy.

Imaging Studies:

Abdominal radiographs

Plain radiographs rarely add to the diagnosis.

Abdominal radiograph findings are normal in many cases of acute appendicitis and should not be obtained routinely.

The presence of a calcified appendiceal fecalith occurs in fewer than 10% of cases.

Radiographic signs suggesting appendicitis include convex lumbar scoliosis, obliteration of right psoas margin, right lower quadrant air-fluid levels, air in the appendix, or localized ileus.

In rare cases, a perforated appendix may produce pneumoperitoneum.

Possible indications for abdominal radiographs include suspected free air, diffuse peritonitis, or small bowel obstruction.

Ultrasonography is the preferred imaging modality in the evaluation of acute appendicitis in pediatrics.

The advantages of ultrasonography include its noninvasiveness, lack of radiation, no contrast medium, and minimal pain.

One disadvantage is that the examination in operator-dependent.

Ultrasonography has had an overall sensitivity of 85% and specificity of 94% in pediatric patients in experienced hands.

Specific findings can support the diagnosis.
- The finding of a noncompressible dilated appendix is a strong indicator of nonperforated appendicitis.
- After perforation, ultrasonography can identify a periappendiceal phlegmon or abscess formation.
- Additional findings that can support the diagnosis of appendicitis include the presence of appendicoliths, fluid in the appendiceal lumen, focal tenderness over the inflamed appendix, and a transverse diameter of 6 mm or more.

Ultrasonography also is useful in diagnosing alternate pathology, such as a tubo-ovarian abscess, ovarian torsion, ovarian cyst, or mesenteric adenitis.

Computed tomography scan

In adults, a CT scan is used widely to diagnose appendicitis.

In children, numerous studies have investigated the use of CT in the evaluation of pediatric appendicitis. CT scanning appears to have its greatest value among patients with large BMI for which ultrasonography is difficult or when ultrasonography is inconclusive. No exact CT protocol is best; some centers use intravenous contrast alone and others use intravenous contrast plus enteral contrast.

CT scans are useful for patients in whom the ultrasonographic findings are equivocal.

A CT scan may be beneficial in complicated cases with abscess formation and bowel-wall thickening. For such cases, oral contrast is most helpful for defining the abscess.

TREATMENT

Section 6 of 10

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Prehospital Care: Emergency medical service (EMS) personnel are well-trained and cognizant of how to assess and begin treatment of the febrile, vomiting, child with abdominal pain.

Intravenous fluid administration, pain management, and antiemetic medication should be administered based on local EMS protocols.

The EMS provider must gather accurate "QRST" data including estimated fluid intake and loss, the child's weight gain or loss, and home remedies and interventions.

Emergency Department Care: One of the difficult challenges in evaluating children with abdominal pain is making a timely diagnosis prior to appendiceal perforation. In the ED, classifying patients with abdominal pain into the following 3 categories may be helpful:

Diagnosis not consistent with appendicitis

This group includes patients whose history and physical examination are not consistent with appendicitis or any significant abdominal process.
Importantly, a complete physical examination, including rectal palpation and urinalysis, should be completed before discharge from the ED.

Classic history for appendicitis

Patients with a classic history for appendicitis require prompt surgical consultation but may not require emergency surgery. In fact, emergency appendectomy (operation within 6 h) in children has no advantages over urgent appendectomy (operation with 12 h) with respect to gangrene and perforation rates, readmissions, postoperative complications, hospital stay, or hospital charges. This does not mean the emergency physician who has made the diagnosis of appendicitis will not contact the surgeon right away, but the hospital admission and course must be discussed with the surgeon, patient, and family.

Antibiotic therapy is an important aspect of the treatment of ruptured appendicitis. Antibiotic therapy should be directed against gram-negative and anaerobic organisms such as Escherichia coli and Bacteroides species. The administration of antibiotics, nasogastric tubes, intravenous lines, urethral catheters, antiemetic medicine, antipyretic medicine, and analgesia should ideally be part of the ED protocol for managing the preoperative child. Proponents of preoperative antibiotic recommend that all children with appendicitis receive gentamicin and clindamycin.

Unclear diagnosis

In these children, the history may be consistent with appendicitis, while the examination is not, or the examination may be suggestive of appendicitis in the face of an unremarkable history. In the latter group, obtaining laboratory studies and radiographs and reevaluating the patient over a few hours to determine the need for surgical consultation is helpful.
Serial examinations of the patient in the ED along with results of the studies may help to clarify the diagnosis.
If uncertainty persists after a period of observation, surgical consultation should be obtained.
Ultrasonography may be useful when the diagnosis is equivocal.

Appendectomy is the definitive treatment for appendicitis.

Pediatric patients with appendicitis can undergo laparoscopic appendectomy (versus open appendectomy) without incurring a greater risk for complications.
Fifteen to 20% of appendectomies are performed in cases for which test results are later determined to be falsely positive, as appendicitis is difficult to diagnose in infants and toddlers.

Nontoxic patients with a localized walled-off abscess may be candidates for initial medical management with antibiotics, followed by an elective appendectomy.

Consultations: Consult a pediatric or general surgeon.

MEDICATION Section 7 of 10

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Preoperative antibiotics are given to children with suspected appendicitis and stopped after surgery if no perforation exists. Patients presenting with perforated appendicitis may be volume depleted and require aggressive fluid resuscitation. The combination of ampicillin, clindamycin, and gentamicin is administered to treat infection from aerobic and anaerobic organisms. Alternative regimens include ampicillin and sulbactam, cefoxitin, cefotetan, piperacillin and tazobactam, ticarcillin and clavulanate, and imipenem and cilastatin.

Further Inpatient Care:

Laparoscopic appendectomy seems to be a safe alternative for the treatment of complicated appendicitis in children.

Potential advantages of laparoscopic appendectomy include reduced postoperative pain and lower wound infection rate.

Pediatric laparoscopic patients have fewer wound problems and shorter duration of oral pain and medication usage.

In addition to advantages for the patient, their parents returned to work quicker than parents of children who had open appendectomy.

Laparoscopy can be diagnostic for alternative diagnosis in the adolescent female.

Complications:

Perforation

Sepsis

Shock

Dehiscence

Wound infection

Bowel obstruction

Prognosis:

The prognosis is generally excellent.

Patient Education:

For excellent patient education resources, visit eMedicine's Esophagus, Stomach, and Intestine Center. Also, see eMedicine's patient education articles, Appendicitis and Abdominal Pain in Children.

MISCELLANEOUS

Section 9 of 10

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Medical/Legal Pitfalls:

Performing a complete examination including examination of the genitals is important. Symptoms and signs of testicular torsion and ectopic pregnancy overlap with appendicitis and have serious morbidity if not quickly diagnosed.

Patients should not be diagnosed with the gastroenteritis unless they have nausea, vomiting, and diarrhea. Patients with nonspecific abdominal complaints should be diagnosed with abdominal pain of unknown etiology. Patients should be instructed to be reevaluated in 8-12 hours by their primary care physician or return to the ED.

Patients with an equivocal examination should be kept for observation and followed-up by serial abdominal examinations. Avoid treating patients with vague abdominal pain with parenteral opiates and then discharging them.

Misdiagnosed patients were younger and more likely to have vomiting before pain onset, constipation, diarrhea, dysuria, and signs and symptoms of upper respiratory infections.

Misdiagnosed patients were more likely to have pain duration of more than 2 days, to have a temperature of more than 38.3°C, and to appear lethargic and irritable.

Special Concerns:

The emergency physician must include the patient (with age appropriate communication) and family in all discussions about the evaluation and treatment plan.

Heed the parent's warnings about whether they think the child has appendicitis or other special concerns.

Keep the patient and family informed about the patient's progress "through the system".

Relieve the patient's pain and discomfort early and often. Do not allow the pediatric patient with appendicitis to be underdosed with analgesia.

Discuss with the surgeons how they would like pediatric patients evaluated and treated; for example, if imaging study should be performed before consultation, or should consultation occur before analgesia. Truly include them, and other consultants, in the emergency department's protocols.

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Section 10 of 10

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Pediatrics, Appendicitis excerpt