Appendicitis (peds): Difference between revisions
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== Pearls ==
== Background ==


*Most common between 6-14 yrs (peak 9y-12y)
*Most common between 9-12yr
*Perforation rate up to 92% in children <3 yrs old
*Perforation rate 90% in children <4yr
*Local tenderness + rigidity at McBurney's point is most reliable clinical sign
*Analgesia does not delay diagnosis!
*NPV of 98% achieved if:
*NPV of 98% achieved if:
**Lack of nausea (or emesis or anorexia)
**Lack of nausea (or emesis or anorexia)
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== Diagnosis ==
== Diagnosis ==
 
*Local tenderness + McBurney's point rigidity most reliable clinical sign
In children with abdominal pain:
===Neonates===
 
*History
{| class="pbNotSortable" cellpadding="1" cellspacing="1" width="200" border="1"
**Vomiting
|-
**Irritability/lethargy
| Sx
*Physical
| +LR
**Abdominal distention
| -LR
===Infants (30 days - 2 yrs)===
|-
*History
| Fever
**Vomiting
| 3.4
**Abdominal pain
| <br/>
**Fever
|-
*Physical
| Rebound
**Diffuse abdominal tenderness
| 3.0
***Localized RLQ TTP occurs <50%
| 0.28
===Preschool (2 - 5yrs)===
|-
*History
| Migration
**Vomiting (often precedes pain)
| 2.5
**Abdominal pain
| 1.2
**Fever
|-
*Physical
| WBC <10k
**RLQ tenderness
| <br/>
===School-age (6 - 12yrs)===
| 0.22
*History
|-
**Vomiting
| ANC <6,750
**Abdominal pain
| <br/>
**Fever
| 0.06
*Physical
|}
**RLQ tenderness
 
===Adolescents (>12yrs)===
== History & Physical ==
*Present similar to adults
 
**RLQ pain
*'''Neonates (birth - 30 days)'''
**Vomiting (occurs after onset of abdominal pain)
**History
**Anorexia
***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 ==
== Laboratory Findings ==
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**Consider if U/S is equivocal OR strong suspicion despite normal U/S
**Consider if U/S is equivocal OR strong suspicion despite normal U/S


==Pediatric Appendicitis Score==
== Pediatric Appendicitis Score ==


*Anorexia - 1pt
*Anorexia - 1pt
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**Gastroenteritis (esp yersinia)
**Gastroenteritis (esp yersinia)


==See Also==
== See Also ==
 
Peds: Abdominal Pain
Peds: Abdominal Pain


== 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
 
</div>
[[Category:Peds]]
<br/>[[Category:Peds]] <br/>[[Category:GI]] <br/><br/><br/>
[[Category:GI]]

Revision as of 23:06, 22 June 2011

Background

  • 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

Diagnosis

  • Local tenderness + McBurney's point rigidity most reliable clinical sign

Neonates

  • 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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