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Appendicitis (peds)
From WikEM
Contents
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%
- Diffuse abdominal tenderness
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
Differential Diagnosis
Pediatric Abdominal Pain
0–3 Months Old
- Emergent
- Nonemergent
3 mo–3 y old
- Emergent
- Nonemergent
3 y old–adolescence
- Emergent
- Nonemergent
Evaluation
Pediatric Appendicitis Score
| Nausea/vomiting | +1 |
| Anorexia | +1 |
| Migration of pain to RLQ | +1 |
| Fever | +1 |
| Cough/percussion/hopping tenderness | +2 |
| RLQ tenderness | +2 |
| Leucocytosis (WBC > 10,000) | +1 |
| Neutrophilia (ANC > 7,500) | +1 |
- Score ≤ 2
- Low risk (0-2.5%)
- Consider discharge home with close follow up
- Score 3-6
- Indeterminate risk
- Consider serial exams, consultation, or imaging
- Score ≥ 7
- High risk
- Consider surgical consultation
Laboratory Findings
- WBC
- <10K is a negative predictor of appendicitis
- Urinalysis
- 7-25% of patients with appendicitis have sterile pyuria
Imaging
Consider in intermediate or higher risk patients
- Ultrasound
- Sn: 88%, Sp: 94%
- Consider as 1st choice in non-obese children
- Indeterminate ultrasound and an Alvarado <5 has an NPV of 99.6%[1]
- CT with contrast
- Sn: 94%, Sp: 95%
- Consider if ultrasound is equivocal OR strong suspicion despite normal ultrasound
Management
- NPO
- IVF (20 mL/kg boluses)
- Analgesia
- Antibiotics
- Ampicillin/sulbactam OR cefoxitin
- Penicillin allergy?
- Gentamycin + (clindamycin or metronidazole)
- Perforation or complicated appendicitis[2]
- IV antibiotic regimen as below:
- Ampicillin 100 mg/kg/d q6hr, max 8 g per dose
- PLUS gentamicin 5 mg/kg QD, max 300 mg
- PLUS metronidazole 30 mg/kg/d q8hr, max 1.5 g
- Daily doses of ceftriaxone and metronidazole just as effective:
- Ceftriaxone 50 mg/kg, max 2 g QD
- PLUS metronidazole 30 mg/kg, max 1.5 g QD
- IV antibiotic regimen as below:
Disposition
- Admission
See Also
References
- ↑ Blitman, et al. Value of focused appendicitis ultrasound and Alverado score in predicting appendicitis in children: Can we reduce the use of CT? AJR. 2015; 204:W707-W712.
- ↑ Yardeni D et al. Single daily dosing ceftriaxone and metronidazole vs standard triple antibiotic regimen for perforated appendicitis in children: a prospective randomized trial. J Pediatr Surg. 2008 Jun; 43(6): 981–985.
Authors
Ross Donaldson, Jordan Swartz, Kevin Lu, Neil Young, Daniel Ostermayer
