Overview
Definition:
Appendicitis in children is acute inflammation of the vermiform appendix, a common surgical emergency requiring prompt diagnosis and management to prevent perforation and its sequelae
The ultrasound-first strategy aims to improve diagnostic accuracy while reducing radiation exposure.
Epidemiology:
It is the most common non-traumatic surgical condition in childhood, with an incidence of approximately 1-2% in children and adolescents
Peak incidence occurs in the second decade of life
There is no significant sex predilection in prepubertal children, but a slight female predominance is seen in adolescents.
Clinical Significance:
Delayed diagnosis leads to increased rates of perforation, abscess formation, peritonitis, and sepsis, resulting in prolonged hospital stays, higher morbidity, and increased healthcare costs
An ultrasound-first approach is crucial for accurate and timely diagnosis in this vulnerable population.
Clinical Presentation
Symptoms:
Initial periumbilical pain migrating to the right lower quadrant within 12-24 hours
Nausea and vomiting, often following the onset of pain
Anorexia and loss of appetite
Low-grade fever
Diarrhea or constipation may occur
Urinary symptoms like dysuria or frequency can be present if the appendix irritates the bladder.
Signs:
Tenderness localized to McBurney's point
Guarding and rebound tenderness in the right lower quadrant
Rovsing's sign (palpation of the left lower quadrant elicits pain in the right lower quadrant)
Psoas sign (pain on passive extension of the right hip)
Obturator sign (pain on internal rotation of the flexed right hip)
Fever
Tachycardia
Signs of dehydration.
Diagnostic Criteria:
There are no universally accepted, objective diagnostic criteria for appendicitis
Diagnosis is primarily based on a combination of clinical findings, laboratory investigations, and imaging
The Modified Alvarado Score can be a useful tool but has limitations in children, necessitating a comprehensive approach.
Diagnostic Approach
History Taking:
Detailed history of pain onset, migration, and character
Associated symptoms like vomiting, fever, and changes in bowel habits
Previous abdominal surgeries or known medical conditions
Family history of appendicitis
Red flags include sudden onset of severe pain, rigidity, or signs of systemic toxicity.
Physical Examination:
Systematic abdominal examination starting from the quadrant least likely to be involved
Assess for distension, bowel sounds, tenderness, guarding, rebound tenderness, and specific signs like Rovsing's, Psoas, and Obturator
Rectal and pelvic examinations may be considered in older children if indicated.
Investigations:
Complete blood count (CBC) typically shows leukocytosis with a left shift, though it can be normal in early appendicitis or perforation
Urinalysis to rule out urinary tract infection
C-reactive protein (CRP) can be elevated
Imaging: Ultrasound (US) is the first-line imaging modality
it can identify an inflamed appendix, appendicolith, periappendiceal fluid, or a normal appendix
Graded compression ultrasound is key
If US is inconclusive or equivocal, CT scan may be used, especially in older children, to visualize the appendix and surrounding structures
MRI is an alternative in pregnant patients or those with contraindications to CT.
Differential Diagnosis:
Mesenteric adenitis, gastroenteritis, constipation, urinary tract infection, intussusception, Meckel's diverticulitis, ovarian pathology (in girls), testicular torsion (in boys), Henoch-Schönlein purpura, inflammatory bowel disease, pneumonia (lower lobe), diabetic ketoacidosis
Distinguishing features often rely on the pattern of pain, associated symptoms, and imaging findings.
Management
Initial Management:
NPO (Nil Per Os) status
Intravenous fluid resuscitation
Analgesia (morphine or fentanyl are commonly used, ensuring pain relief does not mask important physical findings)
Broad-spectrum intravenous antibiotics to cover enteric organisms and gram-positives, initiated preoperatively
Consultation with pediatric surgery.
Medical Management:
Medical management (antibiotics alone) is reserved for uncomplicated appendicitis or for patients who are poor surgical candidates
However, surgery remains the definitive treatment for most cases
Close monitoring is essential if non-operative management is chosen.
Surgical Management:
Appendectomy is the definitive treatment
It can be performed via open laparotomy or laparoscopic appendectomy
Laparoscopic appendectomy is preferred in most cases due to smaller incisions, reduced pain, faster recovery, and shorter hospital stay
Indications for surgery include confirmed appendicitis on imaging or strong clinical suspicion
In case of perforation or abscess, drainage may be required, often followed by interval appendectomy.
Supportive Care:
Aggressive IV fluid management
Electrolyte correction
Nasogastric tube insertion if significant vomiting or bowel obstruction
Pain management
Monitoring vital signs, urine output, and abdominal examination
Nutritional support as tolerated postoperatively
Early mobilization.
Complications
Early Complications:
Perforation
Abscess formation (intra-abdominal, pelvic, or subhepatic)
Peritonitis
Sepsis
Wound infection
Intra-abdominal abscess formation is the most common complication
Delayed diagnosis and management significantly increase complication rates.
Late Complications:
Ileus
Bowel obstruction due to adhesions
Infertility (rare, associated with severe pelvic inflammatory processes)
Incisional hernia
Phantom appendicitis
Recurrence of appendicitis (rare after complete appendectomy).
Prevention Strategies:
Prompt recognition of symptoms
Early and accurate diagnostic imaging (ultrasound-first strategy)
Timely surgical intervention
Appropriate antibiotic use
Meticulous surgical technique to minimize infection and adhesions.
Prognosis
Factors Affecting Prognosis:
Severity of appendicitis at presentation (uncomplicated vs
perforated)
Age of the child
Presence of comorbidities
Promptness of diagnosis and treatment
Development of complications like abscess or sepsis.
Outcomes:
With early diagnosis and treatment, the prognosis for uncomplicated appendicitis is excellent, with full recovery
Children with perforated appendicitis have a higher risk of complications and a longer recovery period
Mortality is rare in developed countries but can be significant in resource-limited settings with delayed care.
Follow Up:
Follow-up is typically brief for uncomplicated appendicitis, focusing on wound healing and return to normal activity
For complicated appendicitis, longer follow-up may be needed to monitor for complications such as abscess formation or bowel obstruction
Patients should be advised to seek medical attention for any new or worsening abdominal pain.
Key Points
Exam Focus:
Ultrasound is the preferred initial imaging modality for suspected appendicitis in children
Differentiating pediatric appendicitis from other causes of abdominal pain is crucial
Laparoscopic appendectomy is the standard surgical approach
Complications increase significantly with delayed diagnosis and perforation.
Clinical Pearls:
Always consider appendicitis in a child with abdominal pain, especially if migrating
Do not be lulled into a false sense of security by a benign initial physical exam
A normal white blood cell count does not rule out appendicitis
In girls of pubertal age, gynecological causes should be considered, but appendicitis remains more common
Ultrasound interpretation requires expertise
equivocal scans warrant further investigation.
Common Mistakes:
Dismissing abdominal pain as gastroenteritis without proper evaluation
Relying solely on laboratory values (like WBC) to diagnose or rule out appendicitis
Delaying surgery due to fear of negative appendectomy
Inadequate fluid resuscitation or pain control
Overuse of CT scan as a first-line investigation in children, increasing radiation exposure.