Appendicitis
Appendicitis: Excerpt from The 5-Minute Pediatric Consult
Vera De Matos, MDAndrew E. Mulberg, MD (4th Edition)
Appendicitis - BASICS
Appendicitis - description
Acute inflammation of the appendix
Appendicitis - epidemiology
Appendicitis - incidence
- Most common acute surgical emergency in childhood
- Peak incidence in teens and young adults, ages 15–25 years (boys 10–14, girls 15–19)
- Affects 250,000 people per year in the US; 1:500 people each year worldwide
- More frequent in males (1.4:1)
Appendicitis - prevalence
Usually occurs in children >2 years of age; rarely considered in children <3 years of age
Appendicitis - risk factors
- Infestation by Enterobius vermicularis or Ascaris lumbricoides
- Recent viral infection
Appendicitis - pathophysiology
- Acute obstruction raises intraluminal pressure, leading to ischemia.
- Bacteria invade the appendiceal wall at sites of ulceration, producing inflammation.
- Necrosis of appendiceal wall results in perforation with fecal contamination of the peritoneum.
Appendicitis - etiology
Obstruction of appendiceal lumen by fecalith, calculi, hyperplastic lymphoid tissue, a worm. or (rarely) a carcinoid tumor
Appendicitis - DIAGNOSIS
- Anorexia, periumbilical pain followed by vomiting
- Accuracy in assessing the time of the onset of symptoms is critical, because the appendix ruptures 24–36 hours later.
Appendicitis - signs & symptoms
Appendicitis - history
Q: Is there constipation and inability to pass gas?A: These are considered traditional cardinal signs for irritation associated with peritoneal or abdominal mesentery.Q: Is there nausea or vomiting?A: Many surgeons feel that vomiting is the cardinal symptom associated with appendicitis.Q: Is there fever?A: Low-grade fever is common in appendicitis; higher fever can indicate an abscess or other infectious disease.Q: Does the pain move, or is there point tenderness associated in the right lower quadrant (RLQ)?A: Typically, there is poorly localized, cramplike mid-abdominal pain that migrates to the RLQ.Q: Other classic features?A: Rectal tenderness, nausea, anorexia; patient prefers to lie still; rarely, secretory diarrhea, more common in infants <2 years of age; change in bowel habits, especially diarrhea; guarding (i.e., voluntary contraction of the abdominal muscle); appendicitis may be presenting with unusual features.Toddlers are not able to explain the time of onset and localization of pain.Appendicitis - physical exam
- Focal peritoneal signs; peritoneal irritation
- Pain at McBurney point; peritoneal irritation
- Psoas sign; peritoneal irritation
- Abdominal rebound tenderness; peritoneal irritation
- Focal tenderness on rectal examination; appendicitis or abscess
- Following perforation, abdomen becomes rigid and tender with absent bowel sounds; patients often febrile, tachypneic, and tachycardic; peritonitis
- Special question: Was the car ride painful (e.g., going over bumps)? (another way to elicit peritoneal irritation)
- Special examination tricks:
- Palpation with stethoscope
- Jiggling bed should produce RLQ pain
- Pain may be elicited by asking patient to cough or hop on right foot (psoas sign); signs of focal peritoneal irritation
- Signs of peritoneal irritation are difficult to elicit in obese children.
Appendicitis - tests
Appendicitis - lab
- Urinanalysis to exclude urinary tract pathology
- CBC; elevated WBC count with left shift
- CRP; acute phase reactant, increased within 12 hours of onset of infection
Appendicitis - imaging
- Abdominal x-ray:
- Often normal
- 8–10% show calcified fecalith
- Cecal wall thickening
- Air-fluid levels suggesting small bowel obstruction
- Indistinct psoas margins
- Pneumoperitoneum (rare)
- Barium enema (not routine): May show evidence of RLQ mass or partial or complete nonfilling of appendix
- Ultrasound: Edema, inflammation, and/or abscess formation. Most valuable to exclude adnexal pathology in girls. Sensitivity depends on the experience of the operator. Average sensitivity 87% and specificity 89.2%
- CT scan (abdomen): Higher sensitivity (90.8%) and specificity (94.2%) than ultrasound. Fluid-filled tubular structure with diameter >6 mm. Fat stranding, abscess or phlegmon in adjacent tissue. Appendicolith seen when present. Focal cecal thickening. Most effective image study to prevent a negative appendectomy and perforation.
Appendicitis - differencial diagnosis
- Infection:
- Gastroenteritis (e.g., Yersinia, Campylobacter)
- Constipation
- Right lower lobe pneumonia
- Mesenteric adenitis
- Typhlitis
- Urinary tract infection
- Pelvic inflammatory disease, tubo-ovarian abscess, or ectopic pregnancy
- Parasitic infection (Trichuris trichiura, Ascaris lumbricoides)
- Inflammatory:
- Inflammatory bowel disease exacerbation
- Anaphylactic purpura
- Hemolytic uremic anemia
- Cholecystitis
- Pancreatitis
- Diverticulitis
- Genetic/Metabolic:
- Diabetes
- Sickle cell disease
- Renal stones
- Hypernatremia
- Crohn disease
- Miscellaneous:
- Function abdominal pain
- Fecalith
- Torsion of testes or ovaries
- Ovarian cyst
- Endometriosis
- Small bowel obstruction
- Rupture of rectus abdominis
Appendicitis - TREATMENT
Appendicitis - general measures
- IV fluids to correct hypovolemia, electrolyte abnormalities
- Broad-spectrum antibiotics should be used if perforation is suspected.
- Nasogastric tube and pain medications may provide comfort preoperatively.
- Abscess may require external drainage.
Appendicitis - diet
- Patient diet should consist of clear liquids (e.g., broth, juices, and herbal teas).
- Introduce foods high in β-carotene. β-Carotene soothes injured mucous membrane and heals tissue.
- Avoid gas-producing foods (e.g., nuts, legumes, broccoli).
- Introduce nutritional supplements or foods high in vitamin B complex for strength, vitamin C for tissue repair, vitamin E for antioxidant, and zinc to aid healing tissue.
Appendicitis - surgery
After the diagnosis is made by a careful history and repeat clinical examination, diagnostic imaging should not delay the surgery.
- Exploratory laparotomy
- Emergency appendectomy: Laparoscopic technique has comparable results to open technique and is associated with faster recovery to daily activity.
Appendicitis - FOLLOW UP
Appendicitis - prognosis
- Recovery rapid
- Prognosis excellent without perforation
- Pitfalls:
- Position of appendix may vary (i.e., location of pain may vary)
- Retroiliac appendix, poorly localized pain
- Retrocecal appendix, right upper quadrant (RUQ) pain
- Appendix in gutter, flank pain
- Pelvic appendix, pain on rectal examination, or diarrhea caused by direct irritation of sigmoid colon
- Appendicitis progresses rapidly in children; perforation often occurs due to delayed diagnosis.
- Pain may resolve briefly following perforation.
Appendicitis - complications
Mostly seen in cases of perforated appendicitis:
- Infections:
- Wound infections are more frequent in perforated appendicitis (1% of all cases)
- Abdominal and pelvic abscesses are also more frequent after a perforated appendicitis (1.3%)
- Intestinal obstruction:
- In patients with perforated appendicitis paralytic ileus may persist after 3–4 days leading to mechanical obstruction. This usually resolves with nasogastric tube decompression.
- Patients with perforated appendicitis may develop bowel obstruction 4 weeks after the appendectomy due to adhesive bands, requiring emergency surgery.
Appendicitis - bibliography
- Alloo J, Gerstle T, Shilyansky J, et al. Appendicitis in children less than 3 years of age: 28-year review. Pediatr Surg Int. 2004;19(12):777–779.
- Andersen BR, Kallehave FL, Andersen HK. Antibiotics versus placebo for prevention of postoperative infection after appendicectomy (Cochrane Review). Cochrane Database Syst Rev. 2001;(3):CD001439.
- Brender JD, Marcuse EK, Koepsell T, et al. Childhood appendicitis: factors associated with perforation. Pediatrics. 1985;76:301–306.
- Dorfman S, Cardozo J, Dorfman D, et al. The role of parasites in acute appendicitis of pediatric patients. Invest Clin. 2003;44(4):337–340.
- Emil S. Risk of rupture in appendicitis. J Am Coll Surg. 2006;203(2):265–266 (author reply).
- Emil S, Taylor M, Ndiforchu F, et al. What are the true advantages of a pediatric appendicitis clinical pathway? Am Surg. 2006;72(10):885–889.
- Evans SR. Appendicitis 2006. Ann Surg. 2006;244(5):661–662.
- Gupta R, Sample C, Bamehriz F, et al. Infectious complications following laparoscopic appendectomy. Can J Surg. 2006;49(6):397–400.
- Klein MD. Clinical approach to a child with abdominal pain who might have appendicitis. Pediatr Radiol. 2007;37(1):11–14.
- Kokoska ER, Minkes RK, Silen ML, et al. Effect of pediatric surgical practice on the treatment of children with appendicitis. Pediatrics. 2001;107(6):1298–1301.
- Lander A. The role of imaging in children with suspected appendicitis: the UK perspective. Pediatr Radiol. 2007;37(1):5–9.
- Lawrence J. Computed tomography in diagnosing suspected appendicitis. Pediatrics. 2001;107(5):1231.
- Lintula H, Kokki H, Vanamo K, et al. The costs and effects of laparoscopic appendectomy in children. Arch Pediatr Adolesc Med. 2004;158(1):11–12.
- Lund DP, Murphy EU. Management of perforated appendicitis in children: A decade of aggressive treatment. J Pediatr Surg. 1994;29(8):1130–1133; discussion 3–4.
- Muehlstedt SG, Pham TQ, Schmeling DJ. The management of pediatric appendicitis: A survey of North American Pediatric Surgeons. J Pediatr Surg. 2004;39(6):875–879; discussion 879.
- Patrick DA. Prospective evaluation of a primary laparoscopic approach for children presenting with simple or complicated appendicitis. Am J Surg. 2006;192(6):750–755.
Appendicitis - CODES
Appendicitis - icd9
- 540.0 Appendicitis with generalized peritonitis
- 540 Acute appendicitis
- 541 Appendicitis, unqualified
Appendicitis - FAQ
- Q: Why is perforation more commonly observed in children with appendicitis?
- A: There is more rapid progression of symptoms that may not follow the classic pattern of RLQ pain. Young children may not be capable of describing their pain. The mesentery in children is thin walled and less effective at walling off an infection.
- Q: Is appendicitis genetically inherited?
- A: Appendicitis does show a tendency to occur in families.
- Q: How long is the typical postoperative recovery period?
- A: Traditional recovery-period rule of thumb is 6 weeks.
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Book Source Details
- Book Title: The 5-Minute Pediatric Consult
- Author(s): M. William Schwartz MD; et al.
- Year of Publication: 2008
- Copyright Details: The 5-Minute Pediatric Consult, Copyright © 2008 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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More About This Book:
Title: The 5-Minute Pediatric Consult
Authors: M. William Schwartz MD; et al.
Publisher: Lippincott Williams & Wilkins
Copyright: 2008
ISBN: 0-7817-7577-9
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