Overview
Definition:
Appendicitis is an acute inflammation of the vermiform appendix, a small, finger-like pouch attached to the cecum
In pediatrics, it is a common surgical emergency requiring prompt diagnosis and management to prevent complications like perforation and peritonitis.
Epidemiology:
Appendicitis is the most common non-traumatic surgical emergency in children, with an incidence peaking in adolescence
It affects boys slightly more often than girls
The incidence varies geographically but remains consistently high globally
Delayed diagnosis is more frequent in younger children.
Clinical Significance:
Accurate and timely diagnosis of pediatric appendicitis is crucial to avoid unnecessary surgery (especially in cases of atypical presentations or negative laparotomies) and to prevent life-threatening complications associated with perforation
Understanding the specific nuances in children is vital for surgical residents preparing for DNB and NEET SS exams.
Clinical Presentation
Symptoms:
Vague periumbilical pain migrating to the right lower quadrant (RLQ) over 12-24 hours
Anorexia is almost universal
Nausea and vomiting typically follow the onset of pain
Fever (usually low-grade initially) may be present
Diarrhea or constipation can occur, especially with retrocecal or pelvic appendicitis.
Signs:
Tenderness at McBurney's point
Rebound tenderness and guarding are classic signs of peritoneal irritation
Rovsing's sign (palpation of the left lower quadrant causes RLQ pain)
Psoas sign (RLQ pain on passive extension of the right hip) and obturator sign (RLQ pain on internal rotation of the flexed right hip) suggest irritation of these muscles, often due to a retrocecal appendix.
Diagnostic Criteria:
No single criterion is pathognomonic
A combination of history, physical examination, laboratory findings, and imaging is used
The modified Alvarado score (or Pediatric Appendicitis Score - PAS) is a useful tool, with scores > 5 suggesting a high probability of appendicitis and prompting further investigation
PAS includes: Migration of pain, Anorexia, Nausea/Vomiting, Tenderness in RLQ, Rebound tenderness, Elevation of temperature, Leukocytosis, Shift to the left.
Diagnostic Approach
History Taking:
Detailed history focusing on the onset, character, and migration of pain
Associated symptoms like anorexia, nausea, vomiting, and fever
Previous abdominal surgeries or medical conditions
Red flags include: severe abdominal distension, hemodynamic instability, suspicion of non-appendiceal pathology.
Physical Examination:
Systematic abdominal examination starting with observation, auscultation, percussion, and finally palpation
Assess for tenderness, guarding, rebound tenderness, and special signs
Digital rectal examination (DRE) can be helpful but is often limited by patient cooperation in children.
Investigations:
Laboratory: Complete blood count (CBC) showing leukocytosis (>10,000-15,000/µL) with a left shift
C-reactive protein (CRP) is often elevated
Urinalysis to rule out urinary tract infection
Imaging: Ultrasound (US) is the initial imaging modality of choice in most pediatric centers due to its safety and accessibility
findings include non-compressible, distended appendix (>6mm diameter), appendicolith, periappendiceal fluid, and abnormal wall thickening
CT scan (with intravenous contrast preferred) is more sensitive and specific, especially in equivocal US cases or when perforation is suspected
findings include enlarged appendix, mural thickening, fat stranding, appendicolith, and extraluminal fluid or abscess
MRI is an alternative in pregnant patients or when radiation avoidance is paramount, offering high sensitivity and specificity without ionizing radiation.
Differential Diagnosis:
Mesenteric adenitis, gastroenteritis, intussusception, Meckel's diverticulitis, urinary tract infection, pneumonia (lower lobe), ovarian pathology (in adolescent females), inflammatory bowel disease, Henoch-Schönlein purpura.
Management
Initial Management:
NPO (nil per os) status
Intravenous fluids for hydration
Analgesia to manage pain (careful use to avoid masking findings)
Broad-spectrum intravenous antibiotics (covering Gram-negative and anaerobic organisms) should be initiated promptly, especially if perforation is suspected or confirmed
Examples: Piperacillin-tazobactam or Ceftriaxone plus Metronidazole.
Surgical Management:
Appendectomy is the definitive treatment
Indications include clinical and/or imaging evidence of appendicitis
Laparoscopic appendectomy is the preferred approach in most pediatric centers due to faster recovery, less pain, and smaller scars
Open appendectomy may be necessary in cases of complicated appendicitis (e.g., extensive adhesions, dense inflammation, or intraoperative complications) or in very young infants where laparoscopic access can be challenging
For perforated appendicitis with an abscess, initial drainage and antibiotics followed by interval appendectomy at 6-8 weeks may be considered, though primary appendectomy is increasingly performed even in such cases.
Supportive Care:
Continuous monitoring of vital signs, fluid balance, and pain levels
Postoperative care includes gradual reintroduction of oral feeding, early mobilization, and continued antibiotic therapy as indicated
Wound care and management of any surgical drains.
Complications
Early Complications:
Perforation leading to localized peritonitis or generalized peritonitis
Intra-abdominal abscess formation
Wound infection
Sepsis.
Late Complications:
Bowel obstruction due to adhesions
Infertility in females due to pelvic adhesions and inflammation (though appendectomy is generally considered safe)
Stump appendicitis (inflammation of the remaining appendiceal stump)
Incisional hernia.
Prevention Strategies:
Prompt diagnosis and surgical intervention are key to preventing complications
Maintaining sterile surgical technique reduces wound infection
Careful dissection during surgery minimizes adhesion formation
Early mobilization and adequate hydration aid in preventing postoperative complications.
Prognosis
Factors Affecting Prognosis:
The primary factor is the presence or absence of perforation at the time of surgery
Uncomplicated appendicitis has an excellent prognosis with low morbidity
Perforated appendicitis carries a higher risk of complications and a longer hospital stay.
Outcomes:
With timely diagnosis and treatment, outcomes for uncomplicated appendicitis are excellent, with most children returning to normal activity within 1-2 weeks after laparoscopic appendectomy
Outcomes for perforated appendicitis are also generally good with appropriate management, but recovery can be prolonged.
Follow Up:
Routine follow-up is usually not required for uncomplicated appendicitis after full recovery
For complicated appendicitis (perforation, abscess), follow-up may include assessment for complications like bowel obstruction or incisional issues
In adolescent females with a history of pelvic appendicitis, discussion regarding potential long-term reproductive health impact may be considered.
Key Points
Exam Focus:
Differentiate pediatric appendicitis from other causes of abdominal pain in children
Recognize classic and atypical presentations
Understand the role and interpretation of US and CT scans
Know the indications for surgery and antibiotic choices
Familiarity with PAS score and its components
Management of perforated appendicitis and appendiceal abscess.
Clinical Pearls:
In younger children, appendicitis pain may be more generalized and they may present with vomiting and fever more prominently than localized pain
Always consider appendicitis in a child with abdominal pain and fever
A negative ultrasound does not completely rule out appendicitis
clinical suspicion should guide further management
Don't delay antibiotics in suspected perforation.
Common Mistakes:
Attributing abdominal pain solely to gastroenteritis without a thorough abdominal exam
Over-reliance on laboratory tests alone without considering clinical presentation
Delayed surgical consult due to diagnostic uncertainty or low clinical suspicion
Inadequate antibiotic coverage for perforated appendicitis.