down in the right lower quadrant but starts periumbilical.
A 9-year-old boy presenting to the emergency
room with acute periumbilical pain
that woke him from sleep.
Remember, pain waking you from sleep is
probably going to be something significant.
The physical exam showed
And according to the mother, he’s had
decreased appetite and a low-grade fever.
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.
Appendicitis is an inflammation of
the appendix, which we all have,
which is a relatively useless
outpouching of intestinal tissue.
The appendix is a normal
diverticulum of the cecum,
which is prone to acute
and chronic inflammation.
It does generally exist in
the right lower quadrant
although sometimes they are retrocolic
and can ascend upward a little bit.
And generally, we all have about a 7%
lifetime risk of developing appendicitis.
The incidence is higher in boys,
and the incidence generally peaks
in the second decade of life.
We do absolutely see this in
younger children as well.
So the pathogenesis of
acute appendicitis is
generally some sort of
Generally, there’s something
at the end of the appendix
that’s blocking the tail piece
from draining correctly.
Examples would be a mass
of stool or a fecalith.
Patient may have a gallstone that
has come out of the gallbladder
and has now landed there.
Very rarely a patient could have a tumor.
And extremely rare, and I have never
seen it in the United States,
but is reported a mass of worms
such as Oxyuriasis vermicularis.
Generally, this progressive
increase in luminal pressure
behind the obstruction
compromise venous outflow from
the wall of the appendix.
Then bacteria proliferate
behind the obstruction
in the pouch of the
appendix and start growing.
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.
Lastly, the appendix will start to necrose.
And if not interfered with and surgically
excised prior to this happening,
it may rupture.
That’s sort of the end
stage of appendicitis,
and that can lead to peritonitis,
septic shock, and even death.
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.
In children under five,
they may just have fever,
diffuse abdominal tenderness, or
sometimes rebound tenderness.
It’s entirely possible that a child may
show up having already perforated.
In fact, it’s common.
They had an abdominal pain
episode, it resolved,
and then gradually, they
started getting worse again,
and now they’re actually
presenting with peritonitis.
They may have guarding,
vomiting, and anorexia.
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.
Remember, most children when asked,
“Where does your belly hurt?”
will nonspecifically point
to their umbilicus.
If a child points to their
right lower quadrant,
you should be concerned
that something is going on.
Anorexia is key.
These children will
generally not want to eat.
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
So on exam, what’s key
is McBurney’s Point.
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.
Patients with pain to
palpation at that spot
should be considered to be
at risk for appendicitis.
Patients will often have
which is to say you’re pushing
gradually and then the pain occurs
when you release your hand
from their abdominal wall.
Likewise, remember that
pain is generally located
down in the right lower quadrant
but starts periumbilical.
There are some key physical exam findings
which are specific to appendicitis.
One is Rovsing’s sign, which
is right lower quadrant pain
when palpating in the
left lower quadrant.
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.
Another is the obturator sign.
This is right lower
quadrant pain or tenderness
on passive internal
rotation of the right hip.
So the patient is relaxed, you
internally rotate the right hip
and they have right lower
quadrant pain or tenderness.
Complications of appendicitis
are not uncommon,
especially in younger children
who are more likely to be delayed
when they make their diagnosis.
So perforation is probably
our most likely complication
where the appendix perforates
because of a delay in diagnosis.
Thrombophlebitis of the portal vein is
possible, a sort of reactive phlebitis.
Again, liver abscesses can occur
generally as a result of the
perforation having occurred
and a seeding of bacteria through
the intraabdominal compartment.
This can also result in
bacteremia, shock, and death.
When we see a patient where
we suspect appendicitis,
typically, we will get
some blood tests.
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.
Typically, children with appendicitis
have a slightly higher white blood count.
It’s not usually super high like 30,
it’s usually something around
the lines of 15 to 18.
Patients may have a high absolute
neutrophil count on their CBC,
which may indicate bacterial infection.
A high CRP is not uncommon.
The CRP is perhaps a better test than
the erythrocyte sedimentation rate
because it’s more temporarily
associated with inflammation.
Sed rate takes a while to raise up, maybe
even a week; CRP will react very quickly.
The urinalysis is commonly
obtained in children
with suspected appendicitis
for two reasons.
First, it is entirely
possible for a child with
appendicitis to have a
This is indicative that
there’s a problem.
Or, perhaps, this patient
has simply pyelonephritis,
which is on your differential diagnosis,
and you’re looking for evidence
of a urinary tract infection.
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.
Sometimes, women may have a
fallopian tubal pregnancy,
or a cyst in the ovary, or other
problems along those lines.
And certainly, in any girl with
abdominal pain and vomiting,
we have to consider
pregnancy as a possibility.
So a pregnancy test is
important for adolescent girls
who are presenting with
The hallmark for a
diagnosis is imaging.
And the best image to get
by far is the ultrasound.
We’ve moved away from other more
harmful imaging processes
like the CT scan.
And the reason for that is to try
to limit radiation exposure.
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.
So generally, we’ll start with
an ultrasound in these children.
Most centers have now moved in children
towards ultrasound as the
primary imaging modality.
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.
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.
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.
In which case, we might
just go to the CT scan.
But generally speaking, in
these younger children,
the ultrasound is actually
much easier to get.
So, first line is ultrasound.
If that’s not working, MRI.
Try to avoid the CAT scan.
Treatment is through surgical removal.
So, the surgeon should be consulted immediately
whenever you suspect an appendicitis.
It’s key to provide pain therapy for
patients who have an appendicitis.
So we will often give them narcotics,
because we know that they’re likely
to recover relatively quickly.
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.
Plus, they generally have to be NPO
status for the planned surgery.