Appendicitis in Children

by Brian Alverson, MD

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    00:05 A 9-year-old boy presenting to the emergency room with acute periumbilical pain that woke him from sleep.

    00:12 Remember, pain waking you from sleep is probably going to be something significant.

    00:17 The physical exam showed rebound tenderness.

    00:20 And according to the mother, he’s had decreased appetite and a low-grade fever.

    00:25 So, what should we be thinking about? What do we have to rule out? Well, the answer is appendicitis, and this is a challenge for all of us who work in the emergency room at a hospital setting of which children have appendicitis and which children don’t.

    00:40 Appendicitis is an inflammation of the appendix, which we all have, which is a relatively useless outpouching of intestinal tissue.

    00:48 The appendix is a normal diverticulum of the cecum, which is prone to acute and chronic inflammation.

    00:57 It does generally exist in the right lower quadrant although sometimes they are retrocolic and can ascend upward a little bit.

    01:07 And generally, we all have about a 7% lifetime risk of developing appendicitis.

    01:14 The incidence is higher in boys, and the incidence generally peaks in the second decade of life.

    01:21 We do absolutely see this in younger children as well.

    01:26 So the pathogenesis of acute appendicitis is generally some sort of luminal obstruction.

    01:33 Generally, there’s something at the end of the appendix that’s blocking the tail piece from draining correctly.

    01:40 Examples would be a mass of stool or a fecalith.

    01:44 Patient may have a gallstone that has come out of the gallbladder and has now landed there.

    01:50 Very rarely a patient could have a tumor.

    01:53 And extremely rare, and I have never seen it in the United States, but is reported a mass of worms such as Oxyuriasis vermicularis.

    02:04 Generally, this progressive increase in luminal pressure that’s happening behind the obstruction compromise venous outflow from the wall of the appendix.

    02:16 Then bacteria proliferate behind the obstruction in the pouch of the appendix and start growing.

    02:24 This leads to ischemia and inflammatory responses within the wall of the appendix, and then eventually, tissue edema, and a neutrophil infiltration of that appendix.

    02:35 Lastly, the appendix will start to necrose.

    02:38 And if not interfered with and surgically excised prior to this happening, it may rupture.

    02:44 That’s sort of the end stage of appendicitis, and that can lead to peritonitis, septic shock, and even death.

    02:53 The symptoms of appendicitis vary by age, and in fact, it’s in these younger children where the symptoms are more nonspecific and this disease can be harder to pick up.

    03:04 In children under five, they may just have fever, diffuse abdominal tenderness, or sometimes rebound tenderness.

    03:12 It’s entirely possible that a child may show up having already perforated.

    03:16 In fact, it’s common.

    03:18 They had an abdominal pain episode, it resolved, and then gradually, they started getting worse again, and now they’re actually presenting with peritonitis.

    03:26 They may have guarding, vomiting, and anorexia.

    03:31 In a child who’s a little bit older, 5 to 12 years of age, they may just have abdominal pain, vomiting, and now they may specifically be able to tell you they’re having right lower quadrant tenderness as opposed to other areas.

    03:44 Remember, most children when asked, “Where does your belly hurt?” will nonspecifically point to their umbilicus.

    03:50 If a child points to their right lower quadrant, you should be concerned that something is going on.

    03:55 Anorexia is key.

    03:57 These children will generally not want to eat.

    04:01 In older children, it’s more like adult appendicitis where patients present with fever, anorexia, periumbilical pain that gradually moves down to the right lower quadrant, and especially pain before vomiting.

    04:15 So on exam, what’s key is McBurney’s Point.

    04:18 As you can see on the slide here, that area right there along that diagonal line between the umbilicus and the anterior superior iliac crest where the appendix generally resides.

    04:30 Patients with pain to palpation at that spot should be considered to be at risk for appendicitis.

    04:37 Patients will often have rebound tenderness, which is to say you’re pushing gradually and then the pain occurs when you release your hand from their abdominal wall.

    04:48 Likewise, remember that pain is generally located down in the right lower quadrant but starts periumbilical.

    04:55 There are some key physical exam findings which are specific to appendicitis.

    05:00 One is Rovsing’s sign, which is right lower quadrant pain when palpating in the left lower quadrant.

    05:08 Another is the Psoas sign, which is right lower quadrant pain and tenderness when the right leg is extended while applying counter resistance to the right hip.

    05:21 Another is the obturator sign.

    05:24 This is right lower quadrant pain or tenderness on passive internal rotation of the right hip.

    05:32 So the patient is relaxed, you internally rotate the right hip and they have right lower quadrant pain or tenderness.

    05:40 Complications of appendicitis are not uncommon, especially in younger children who are more likely to be delayed when they make their diagnosis.

    05:51 So perforation is probably our most likely complication where the appendix perforates because of a delay in diagnosis.

    06:00 Thrombophlebitis of the portal vein is possible, a sort of reactive phlebitis.

    06:06 Again, liver abscesses can occur generally as a result of the perforation having occurred and a seeding of bacteria through the intraabdominal compartment.

    06:16 This can also result in bacteremia, shock, and death.

    06:22 When we see a patient where we suspect appendicitis, typically, we will get some blood tests.

    06:29 Those blood tests may help nudge you in one direction or another, but we have to remember that it is entirely possible to have appendicitis in a completely normal laboratory profile.

    06:42 Typically, children with appendicitis have a slightly higher white blood count.

    06:47 It’s not usually super high like 30, it’s usually something around the lines of 15 to 18.

    06:55 Patients may have a high absolute neutrophil count on their CBC, which may indicate bacterial infection.

    07:04 A high CRP is not uncommon.

    07:08 The CRP is perhaps a better test than the erythrocyte sedimentation rate because it’s more temporarily associated with inflammation.

    07:17 Sed rate takes a while to raise up, maybe even a week; CRP will react very quickly.

    07:25 The urinalysis is commonly obtained in children with suspected appendicitis for two reasons.

    07:31 First, it is entirely possible for a child with appendicitis to have a sterile pleocytosis.

    07:37 This is indicative that there’s a problem.

    07:40 Or, perhaps, this patient has simply pyelonephritis, which is on your differential diagnosis, and you’re looking for evidence of a urinary tract infection.

    07:51 Remember that in that right lower quadrant, there are other structures, and especially in your adolescent women or young girls, there is the ovary, there is the fallopian tube.

    08:02 Sometimes, women may have a fallopian tubal pregnancy, or a cyst in the ovary, or other problems along those lines.

    08:11 And certainly, in any girl with abdominal pain and vomiting, we have to consider pregnancy as a possibility.

    08:18 So a pregnancy test is important for adolescent girls who are presenting with suspected appendicitis.

    08:26 The hallmark for a diagnosis is imaging.

    08:30 And the best image to get by far is the ultrasound.

    08:34 We’ve moved away from other more harmful imaging processes like the CT scan.

    08:42 And the reason for that is to try to limit radiation exposure.

    08:46 Remember that the ovaries are right next to the appendicitis, and ovarian exposure to radiation is bad in terms of preventing ovarian cancer down the road.

    08:58 So generally, we’ll start with an ultrasound in these children.

    09:01 Most centers have now moved in children towards ultrasound as the primary imaging modality.

    09:07 If the ultrasound image is difficult to obtain, or if we can’t see the appendicitis or find the appendix with an ultrasound, we may move on to another test such as an MRI.

    09:20 And our techniques are getting better with MRI so that for older children, they’re generally able to hold still for the duration of the procedure.

    09:29 If it’s a very young child, and these very young children generally don’t get appendicitis, we may have to sedate the child for an MRI.

    09:37 In which case, we might just go to the CT scan.

    09:40 But generally speaking, in these younger children, the ultrasound is actually much easier to get.

    09:45 So, first line is ultrasound.

    09:48 If that’s not working, MRI.

    09:51 Try to avoid the CAT scan.

    09:55 Treatment is through surgical removal.

    09:58 So, the surgeon should be consulted immediately whenever you suspect an appendicitis.

    10:03 It’s key to provide pain therapy for patients who have an appendicitis.

    10:09 So we will often give them narcotics, because we know that they’re likely to recover relatively quickly.

    10:16 Hydration is of course important, and we’ll generally place IVs in these children and provide them IV hydration because they generally have anorexia and don’t wish to eat or drink.

    10:27 Plus, they generally have to be NPO status for the planned surgery.

    About the Lecture

    The lecture Appendicitis in Children by Brian Alverson, MD is from the course Pediatric Gastroenterology. It contains the following chapters:

    • Appendicitis: Pathology
    • Appendicitis: Signs & Symptoms
    • Appendicitis: Clinical Presentation
    • Appendicitis: Diagnosis & Management

    Included Quiz Questions

    1. Ultrasound
    2. CT of the abdomen
    3. MRI of the abdomen
    4. Upper GI with small bowel follow through
    5. Tagged RBC scan
    1. Fecalith
    2. Gallstone
    3. Worm
    4. Tumor
    5. Twisting on itself
    1. Murphy's sign
    2. McBurney's point tenderness
    3. Rovsing's sign
    4. Rebound tenderness
    5. Psoas sign
    1. Necrosis and rupture of the appendix may occur without immediate surgery
    2. Appendicitis will resolve on its own
    3. Antibiotics are a good alternative to surgery
    4. Surgery may be deferred until the acute episode resolves
    5. He can be discharged after a bolus dose of morphine and promethazine

    Author of lecture Appendicitis in Children

     Brian Alverson, MD

    Brian Alverson, MD

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