Appendicitis (peds): Difference between revisions

No edit summary
No edit summary
Line 1: Line 1:
==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:
{| class="pbNotSortable" width="200" cellspacing="1" cellpadding="1"
| 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==
<div>
* 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 
<span style="line-height: 21px">'''<font size="17px"><font face="&#39;Segoe UI&#39;, &#39;Lucida Grande&#39;, Arial, sans-serif">Pediatric Appendicitis Score</font></font>'''</span>
* 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
</div><div>
* 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)
<span style="line-height: 21px">'''<font size="17px"><font face="&#39;Segoe UI&#39;, &#39;Lucida Grande&#39;, Arial, sans-serif">See Also</font></font>'''</span>
</div>
[/Abdominal-Pain-(Peds) Peds:  Abdominal Pain (Peds)]
====
==Source==
Bundy DG et al. Does this child have appendicitis? JAMA 2007; 298:438-451, UpToDate
<div id="wikiedit" style="display: none"><div id="editor-panel" class="box">
=Appendicitis (Peds)[/rename.php?renamepage=Appendicitis%20%28Peds%29  ]=
{| id="edit-panel" style="table-layout: fixed; width: 100%"
|-
|
<div id="editframe"></div><div id="edit-toolbar-outer" style="background: #f7f7f7; border: 1px solid #ddd; border-top: 1px solid #f7f7f7"><div id="revcomment_section" style="display: none"><div id="revcomment_top">Describe your changes:[# (hide this)]</div><div class="entry"></div></div><div id="edit-toolbar" class="secondarypagetoolbar"><span id="show_tags" style="float: right; margin: 5px">Edit tags</span><span id="show_revcomment" style="float: right; margin: 5px">Describe your changes</span><span id="autosave_msg" class="aux"></span>[#pbedit <span id="saveButton" class="iconbutton savepage">'''Save'''</span>][# <span id="saveAndContinue" class="iconbutton savecontinue" style="position: relative">Save and Continue</span>]<span style="line-height: 30px">or [/w/page/11229287/Appendicitis-(Peds)?unlock=true Cancel]</span><span id="save_msg" class="aux loading"></span></div><div style="clear: both; line-height: 1px"><font size="1px"> </font></div><div id="tag-settings" class="page-settings-panel" style="margin-top: 0.75em; display: none">
{| width="100%"
| style="width: 4em" |
Tags
|
e.g. report, new release, planning
|}
<div style="clear: both; line-height: 1px"><font size="1px"> </font></div><div id="tagcloud"></div></div></div>
|
<div id="editor-column" class="thingbar" style="margin-left: 12px"><div id="edit-tools">
====Page Tools====
[/rename.php?renamepage=Appendicitis%20%28Peds%29 Rename this page] [# Delete this page]<div class="editor-module"><div class="header">
===Insert links===
Insert links to other pages or uploaded files.
</div><div class="editor-module-tabs">[# Pages] [# Images and files]</div><div class="content"><div id="thingbar-pages" style="display: none"><div style="border-bottom: 1px dotted #bbb; padding-bottom: 0.5em; margin-bottom: 0.5em"><font size="10px">[javascript:void(0); Insert a link to a new page]</font></div>
# <div><center><span id="thingbarLoadIcon"></span> Loading...</center></div>
</div><div id="thingbar-images" style="display: none"><div id="thingbar-upload" style="border-bottom: 1px dotted #bbb; padding-bottom: 0.5em; margin-bottom: 0.5em"><font size="10px"></font></div>
# No images or files uploaded yet.
<div style="border-top: 1px dotted #bbb; padding-top: 0.5em; margin-top: 0.5em"><font size="10px">[javascript:void(0); Insert image from URL]</font></div></div></div></div></div>
'''Tip:''' To turn text into a link, highlight the text, then click on a page or file from the list above.
</div>
|}
</div></div>
==Pearls==
==Pearls==


Revision as of 03:57, 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

[/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

Retrieved from "https://www.wikem.org/w/index.php?title=Appendicitis_(peds)&oldid=948"