Appendicitis (peds)

Revision as of 16:42, 29 July 2015 by Neil.m.young (talk | contribs)

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

Clinical Features

  • 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

Diagnosis

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

Laboratory Findings

  • WBC
    • <10K is strong negative predictor for appy
  • 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

Differential Diagnosis

Pediatric Abdominal Pain

0–3 Months Old

3 mo–3 y old

3 y old–adolescence

Management

See Also

Source

  • UpToDate
  • Tintinalli