ACUTE APPENDICITIS
IN CHILDREN
LECTURE FROM PAEDIATRIC SURGERY DEPARTAMENT OF
VOLGOGRAD STATE MEDICAL UNIVERSITY
O.I. VERBIN
AUTOR
,
ASSISTENT OF PAEDIATRIC SURGERY DEPARTAMENT
POSITIONS OF APPENDIX
PROFFERED APPENDICEAL
ACTIVITIES FUNCRIONS:
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lymphatic,
exocrine,
endocrine,
neuromuscular.
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.
RISK OF DEVELOPING
APPENDICITIS WITH AGE
Age:
 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 5085%.
Perforated appendicitis
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.
Causes of right iliac fossa
mass
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Appendix mass
Crohn's disease
Caecal carcinoma
Mucocele of the gallbladder
Psoas abscess
Pelvic kidney
Ovarian cyst
Causes of right iliac fossa
pain
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Appendicitis
Urinary tract infection
Non-specific abdominal pain
Pelvic inflammatory disease
Renal colic
Ectopic pregnancy
Constipation
CLINICAL FEATURES OF
APPENDICITIS
 Central abdominal pain moving to right iliac
fossa
 Nausea, vomiting, anorexia
 Low-grade pyrexia
 Localised tenderness in right iliac fossa
 Right iliac fossa peritonism
 Percussion tenderness is a kinder sign of
peritonism than rebound
 Rovsing's sign = pain in right iliac fossa on
palpation of the left iliac fossa
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.
History:
 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.
History:
 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.
History:
 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.
History:
 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.
History:
 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.
History:
 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.
History:
 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.
Physical:
 Observation of the child's interaction and
gait prior to the examination can be
extremely helpful.
Physical:
 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 leftsided palpation and strongly suggests peritoneal
irritation
Physical:
 The psoas sign is determined by placing
the child on the left side and
hyperextending the right leg.
Physical:
 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.
Physical:
 The cough sign (sharp pain in the RLQ
after a voluntary cough) is suggestive of
peritoneal irritation.
Physical:
 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.
rectal examination
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.
DIFFERENTIAL :
Pancreatitis
Pediatrics, Diabetic Ketoacidosis
Pediatrics, Gastroenteritis
Ovarian Cysts 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
Prehospital Care:
 Emergency medical service (EMS) personnel are welltrained 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.
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,
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.
LAPAROSCOPIC
APPENDECTOMY
LAPAROSCOPIC
APPENDECTOMY 2
Medical Pitfalls:
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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.