Appendicitis (peds)
This page is for pediatric patients. For adult patients, see: appendicitis
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
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
0–3 Months Old
- Emergent
- Nonemergent
3 mo–3 y old
- Emergent
- Intussusception
- Testicular Torsion
- Trauma
- Volvulus
- Appendicitis
- Toxic megacolon
- Vaso-occlusive crisis
- Nonemergent
3 y old–adolescence
- Emergent
- Appendicitis
- DKA
- Vaso-occlusive crisis
- Toxic ingestion
- Testicular Torsion
- Ovarian Torsion
- Ectopic Pregnancy
- Trauma
- Toxic megacolon
- Inflammatory bowel disease
- Gastric ulcer disease
- Ovarian cyst
- Pregnancy
- Pancreatitis
- Cholecystitis
- Intussusception (to age 6)
- 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
Pediatric Appendicitis Risk Calculator (pARC)
- pARC score shown to outperform Pediatric Appendicitis Score. pARC score accurately assesses risk of appendicitis in children age 5 years and older in community EDs [1]
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%[2]
- 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?
- Gentamicin + (clindamycin OR
- metronidazole)
- Perforation or complicated appendicitis[3]
- IV antibiotic regimen as below:
- Ampicillin 100 mg/kg/d q6hr, max 8 g per dose AND
- Gentamicin 5 mg/kg QD, max 300 mg AND
- 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 AND
- Metronidazole 30 mg/kg, max 1.5 g QD
- IV antibiotic regimen as below:
Disposition
- Admission
See Also
References
- Cotton D, et al., Validation of the Pediatric Appendicitis Risk Calculator (pARC) in a Community Emergency Department Setting. Annals Emrg. Med. 2019; 74(4) 471-480
- 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.
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