Appendicitis The 5 Minute Pediatric Consult


	Appendicitis

Andrew E. Mulberg

Database
Differential Diagnosis
Data Gathering
Physical Examination
Laboratory Aids
Therapy
Follow-Up
Common Questions and Answers
Bibliography

DATABASE

DEFINITION

Acute inflammation of the appendix.

CAUSES

Obstruction of appendiceal lumen by fecalith, calculi, or hyperplastic lymphoid tissue
Torsion of appendix, leading to ischemic necrosis

PATHOLOGY

Acute obstruction raises intraluminal pressure, leading to ischemia.
Bacteria invade the appendiceal wall at sites of ulceration producing inflammation.
Necrosis of the wall results in perforation with fecal contamination of the peritoneum.

EPIDEMIOLOGY

Usually occurs in children over 2 years
Peak incidence in teens and young adults

GENETICS

Familial tendency toward appendicitis

COMPLICATIONS

Perforation occurs in up to three-fourths of patients under age 4 and in two-thirds of patients between the ages of 5 and 8.

DIFFERENTIAL DIAGNOSIS

INFECTION

Gastroenteritis (e.g., Yersinia, Campylobacter)
Constipation
Right lower lobe pneumonia
Mesenteric adenitis
Typhlitis
Urinary tract infection
Pelvic inflammatory disease, tubo-ovarian abscess, or ectopic pregnancy

INFLAMAMATORY

Inflammatory bowel disease exacerbation
Anaphylactic purpura
Hemolytic uremic anemia

GENETIC/METABOLICAL

Diabetes
Sickle and Sickle C disease
Renal stone
Hypernatremia

MISCELLANEOUS

Functional abdominal pain
Fecalith
Tortion of testes
Tortion of ovary
Ovarian cyst
Endometriosis

DATA GATHERING

HISTORY

Question: Is there vomiting?
Significance: Many surgeons feel that vomiting is the cardinal symptom associated with appendicitis.

Question: Is there fever?
Significance: Low-grade fever is common in appendicitis; higher fever can be an abscess or other infectious disease.

Question: Does the pain move?
Significance: Typically, there is poorly localized, crampy midabdominal pain that migrates to right lower quadrant (RLQ).

Question: Ask about other classic features?

Nausea, anorexia
Patient prefers to lie still
Rarely secretory diarrhea
Change in bowel habits, especially diarrhea

Significance: Appendicitis may be presenting with unusual features.

PHYSICAL EXAMINATION

Finding: Focal peritoneal signs
Significance: Peritoneal irritation

Finding: Pain at McBurney point
Significance: Peritoneal irritation

Finding: Hypoactive bowel sounds
Significance: Decreased motility secondary to inflammation

Finding: Focal tenderness on rectal examination
Significance: Appendicitus or abscess

Finding: Following perforation, abdomen becomes rigid and tender with absent bowel sounds; patients often febrile, tachypneic, and tachycardic
Significance: Peritonitis

SPECIAL QUESTIONS

Finding: Was car ride painful, e.g., going over bumps?
Significance: Another way to elicit peritoneal irritation

PHYSICAL EXAMINATION TRICKS

Palpation with stethoscope
Jiggling bed should produce RLQ pain
Pain may be elicited by asking patient to cough or to hop on right foot.

LABORATORY AIDS

TESTS

Test: CBC
Significance: Elevated WBC count with left shift

IMAGING

Test: Abdominal x-ray
Significance:

often normal
8% to 10% show calcified fecalith
Cecal-wall thickening
Air-fluid levels
Indistinct psoas margins

Test: Barium enema
Significance: May show evidence of RLQ mass or partial or complete non-filling of appendix.

Test: Ultrasound
Significance: Edema, inflammation, and/or abscess formation

THERAPY

IV fluids to correct hypovolemia, electrolyte abnormalities
Emergency appendectomy
Broad-spectrum antibiotics should be used if perforation is suspected.
Nasogastric tube and pain medications may provide comfort preoperatively.
Abscess may require external drainage.

FOLLOW-UP

Recovery rapid
Prognosis excellent without perforation, very good with perforation (mortality, 1%)

PITFALLS

Position of appendix may vary, i.e., location of pain may vary.
Retroiliac appendix—poorly localized pain
Retrocecal appendix—RUQ pain
Appendix in gutter—flank pain
Pelvic appendix—pain on rectal examination, or diarrhea caused by direct irritation of sigmoid colon
Appendicitis progresses rapidly in children; perforation often occurs due to delayed diagnosis
Pain may resolve briefly following perforation

COMMON QUESTIONS AND ANSWERS

Q: Why is perforation more commonly observed in children with appendicitis?
A: There is a more rapid progression of symptoms that may not follow the classic pattern of RLQ pain. Young children may not be capable of describing their pain. The mesentery in children is thin walled and less effective at walling off an infection.

Q: Is appendicitis genetically inherited?
A: Appendicitis does show a tendency to occur in families.

ICD-9-CM 540.9

BIBLIOGRAPHY

Brender JD, Marcuse EK, Koepsell T, Hatch EI. Childhood appendicitis: factors associated with perforation. Pediatrics 1985;76:301–306.

Ravitch MM. Appendicitis. Pediatrics 1982;70:414–419.

Schnaufer L, Mahboubi S. Abdominal emergencies. In: Ludwig S, Fleisler G, eds. Pediatric emergency medicine, 3rd ed. Philadelphia: Williams & Wilkins 1993:1309–1313.

Shandling B, Fallis J. Acute appendicitis. In: Behrman RE, ed. Nelson textbook of pediatrics, 4th ed. Philadelphia: WB Saunders, 1992:987–990.

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