ACUTE APPENDICITIS ACUTE APPENDICITIS IN CHILDRENIN CHILDREN

LECTURE FROM PAEDIATRIC SURGERY DEPARTAMENT OF LECTURE FROM PAEDIATRIC SURGERY DEPARTAMENT OF VOLGOGRAD STATE MEDICAL UNIVERSITYVOLGOGRAD STATE MEDICAL UNIVERSITY

AUTOR AUTOR O.I. VERBINO.I. VERBIN, , ASSISTENT OF PAEDIATRIC SURGERY DEPARTAMENT ASSISTENT OF PAEDIATRIC SURGERY DEPARTAMENT

POSITIONS OF APPENDIX POSITIONS OF APPENDIX

PROFFEREDPROFFERED APPENDICEAL APPENDICEAL ACTIVITIESACTIVITIES FUNCRIONSFUNCRIONS::

lymphatic, lymphatic, exocrine, exocrine, endocrine, endocrine, neuromuscular. neuromuscular.

The role of race, ethnicity, health The role of race, ethnicity, health insurance, education, access to insurance, education, access to healthcare, and economic status on the healthcare, and economic status on the development and treatment of development and treatment of appendicitis are widely debated. Cogent appendicitis are widely debated. Cogent arguments have been made on both arguments have been made on both sides for and against the significance of sides for and against the significance of each socioeconomic or racial condition. each socioeconomic or racial condition.

Sex:Sex:

The male-to-female ratio is approximately The male-to-female ratio is approximately 2:1. 2:1.

RISK OF DEVELOPING RISK OF DEVELOPING APPENDICITIS WITH AGEAPPENDICITIS WITH AGE

AgeAge::

The mean age in the pediatric population The mean age in the pediatric population is 6-10 years.is 6-10 years.

Appendicitis is rare in the neonate, and Appendicitis is rare in the neonate, and the diagnosis in this age group is typically the diagnosis in this age group is typically made after perforation.made after perforation.

Younger children have a higher rate of Younger children have a higher rate of perforation, with reported rates of 50-perforation, with reported rates of 50-85%.85%.

PPerforated appendicitis erforated appendicitis

Mortality/Morbidity Mortality/Morbidity

At the time of diagnosis, the rate of At the time of diagnosis, the rate of perforation varies from 17-40%, with a perforation varies from 17-40%, with a higher frequency occurring in younger higher frequency occurring in younger age groups.age groups.

The mortality rate for children with The mortality rate for children with appendicitis ranges from 0.1-1%.appendicitis ranges from 0.1-1%.

Perforation increases the complication Perforation increases the complication rate.rate.

Causes of right iliac fossa Causes of right iliac fossa massmass

Appendix mass Appendix mass Crohn's disease Crohn's disease Caecal carcinoma Caecal carcinoma Mucocele of the gallbladder Mucocele of the gallbladder Psoas abscess Psoas abscess Pelvic kidney Pelvic kidney Ovarian cyst Ovarian cyst

Causes of right iliac fossa Causes of right iliac fossa pain pain

Appendicitis Appendicitis Urinary tract infection Urinary tract infection Non-specific abdominal pain Non-specific abdominal pain Pelvic inflammatory disease Pelvic inflammatory disease Renal colic Renal colic Ectopic pregnancy Ectopic pregnancy Constipation Constipation

CCLINICAL FEATURES OF LINICAL FEATURES OF APPENDICITISAPPENDICITIS

Central abdominal pain moving to right iliac Central abdominal pain moving to right iliac fossa fossa

Nausea, vomiting, anorexia Nausea, vomiting, anorexia Low-grade pyrexia Low-grade pyrexia Localised tenderness in right iliac fossa Localised tenderness in right iliac fossa Right iliac fossa peritonism Right iliac fossa peritonism Percussion tenderness is a kinder sign of Percussion tenderness is a kinder sign of

peritonism than rebound peritonism than rebound Rovsing's sign = pain in right iliac fossa on Rovsing's sign = pain in right iliac fossa on

palpation of the left iliac fossa palpation of the left iliac fossa

History: History:

Understanding the typical clinical manifestations of appendicitis is Understanding the typical clinical manifestations of appendicitis is important in order to make an early and accurate diagnosis prior important in order to make an early and accurate diagnosis prior to perforation. The classic history of anorexia and periumbilical to perforation. The classic history of anorexia and periumbilical pain, followed by right lower quadrant (RLQ) pain and vomiting, is pain, followed by right lower quadrant (RLQ) pain and vomiting, is observed in fewer than 60% of patients. The clinician is more observed in fewer than 60% of patients. The clinician is more likely to make the diagnosis by maintaining a high degree of likely to make the diagnosis by maintaining a high degree of suspicion, a broad differential diagnosis, and looking for the suspicion, a broad differential diagnosis, and looking for the atypical case rather than the classic appendicitis (1-2 d of fever, atypical case rather than the classic appendicitis (1-2 d of fever, vomiting, right lower quadrant pain, anorexia). vomiting, right lower quadrant pain, anorexia).

Vomiting, RLQ pain, tenderness, and guarding are significantly (all Vomiting, RLQ pain, tenderness, and guarding are significantly (all P less than 0.001) associated with appendicitis. P less than 0.001) associated with appendicitis.

HistoryHistory::

The initial symptom is poorly defined The initial symptom is poorly defined periumbilical pain, often associated with periumbilical pain, often associated with anorexia.anorexia. Acute onset of severe pain is typically present with Acute onset of severe pain is typically present with

acute ischemic conditions, such as volvulus, acute ischemic conditions, such as volvulus, testicular torsion, ovarian torsion, or testicular torsion, ovarian torsion, or intussusception.intussusception.

In appendicitis, nausea and vomiting develop shortly In appendicitis, nausea and vomiting develop shortly after onset of pain.after onset of pain.

In most cases of appendicitis, abdominal pain In most cases of appendicitis, abdominal pain precedes vomiting.precedes vomiting.

HistoryHistory::

After a few hours, the pain shifts to the After a few hours, the pain shifts to the RLQ due to inflammation of the parietal RLQ due to inflammation of the parietal peritoneum.peritoneum. This pain is more intense, continuous, and This pain is more intense, continuous, and

more localized than the initial pain.more localized than the initial pain. This shift of pain rarely occurs in other This shift of pain rarely occurs in other

abdominal conditions.abdominal conditions.

HistoryHistory::

Most children with appendicitis either are Most children with appendicitis either are afebrile or have a low-grade fever.afebrile or have a low-grade fever. High fever is not a common presenting High fever is not a common presenting

feature unless perforation has occurred.feature unless perforation has occurred. Vomiting and fever are more frequent in Vomiting and fever are more frequent in

children with appendicitis than in children children with appendicitis than in children with other causes of abdominal pain.with other causes of abdominal pain.

HistoryHistory::

A careful family history should be obtained for A careful family history should be obtained for every child in whom acute appendicitis is every child in whom acute appendicitis is suspected.suspected. Multiple studies have demonstrated that children Multiple studies have demonstrated that children

who have appendicitis are more than likely to have a who have appendicitis are more than likely to have a positive family history.positive family history.

To date, not enough evidence exists to support a To date, not enough evidence exists to support a major gene for appendicitis. Nonetheless, a positive major gene for appendicitis. Nonetheless, a positive family history of appendicitis must be appreciated family history of appendicitis must be appreciated and respected when evaluating a child with and respected when evaluating a child with abdominal pain.abdominal pain.

HistoryHistory::

Evaluation rules and algorithms have been proposed to Evaluation rules and algorithms have been proposed to help the clinician make the correct diagnosis and help the clinician make the correct diagnosis and treatment plan. Nothing in emergency medicine is treatment plan. Nothing in emergency medicine is guaranteed, but decision rules can predict which guaranteed, but decision rules can predict which children are at low risk for appendicitis.children are at low risk for appendicitis. One such numerically based system is based on a 6-part One such numerically based system is based on a 6-part

scoring system: nausea (2 points), history of focal RLQ pain (2 scoring system: nausea (2 points), history of focal RLQ pain (2 points), migration of pain (1 point), difficulty walking (1 point), points), migration of pain (1 point), difficulty walking (1 point), rebound tenderness/pain with percussion (2 points), and rebound tenderness/pain with percussion (2 points), and absolute neutrophil count of >6.75 X 103/absolute neutrophil count of >6.75 X 103/mmL (6 points).L (6 points).

A score A score << 5 had a sensitivity of 96.3% (95% confidence 5 had a sensitivity of 96.3% (95% confidence interval [CI], 87.5-99.0), a negative predictive value of 95.6% interval [CI], 87.5-99.0), a negative predictive value of 95.6% (95% CI, 90.8-99.0), and a negative likelihood ratio of 0.102 (95% CI, 90.8-99.0), and a negative likelihood ratio of 0.102 (95% CI, 0.026-0.405) in the validation set.(95% CI, 0.026-0.405) in the validation set.

HistoryHistory::

The keys to any evaluation and treatment plan The keys to any evaluation and treatment plan that involve equivocal history, physical that involve equivocal history, physical examination findings, and inconclusive examination findings, and inconclusive supporting test results include relieving the supporting test results include relieving the patient's pain and discomfort early and often, patient's pain and discomfort early and often, communicating with the patient and family communicating with the patient and family about the plans, discovering and addressing about the plans, discovering and addressing concerns, repeating the examination often, concerns, repeating the examination often, adjusting the differential diagnosis, and adjusting the differential diagnosis, and keeping the patient for observation if a firm keeping the patient for observation if a firm diagnosis is not made or for follow-up. diagnosis is not made or for follow-up.

HistoryHistory::

Algorithms, scoring systems, imaging Algorithms, scoring systems, imaging studies, and consultation reports are part studies, and consultation reports are part of the clinician's armamentarium. Always of the clinician's armamentarium. Always document what actions were taken or document what actions were taken or why actions were not taken in a particular why actions were not taken in a particular way. Let the record reflect the thought way. Let the record reflect the thought process and support for the thought process and support for the thought process with reports such as algorithms process with reports such as algorithms and scoring systems.and scoring systems.

Physical: Physical:

Children vary in their ability to cooperate Children vary in their ability to cooperate with the physical examination. It is with the physical examination. It is important to tailor the physical important to tailor the physical examination with respect to the child's examination with respect to the child's age and developmental stage. It is age and developmental stage. It is important to exclude extra-abdominal important to exclude extra-abdominal causes of abdominal pain. causes of abdominal pain.

Physical: Physical:

Observation of the child's interaction and Observation of the child's interaction and gait prior to the examination can be gait prior to the examination can be extremely helpful.extremely helpful.

Physical: Physical:

A child with appendicitis typically prefers to lie A child with appendicitis typically prefers to lie still due to peritoneal irritation.still due to peritoneal irritation. Observing the child's facial expression during Observing the child's facial expression during

palpation of the abdomen can be helpful in eliciting palpation of the abdomen can be helpful in eliciting the location and intensity of any abdominal pain.the location and intensity of any abdominal pain.

Localization of the pain depends on the position of Localization of the pain depends on the position of the appendix.the appendix.

Typically, maximal tenderness can be found at Typically, maximal tenderness can be found at McBurney point in the right lower quadrant.McBurney point in the right lower quadrant.

Rovsing sign is pain in the RLQ in response to left-Rovsing sign is pain in the RLQ in response to left-sided palpation and strongly suggests peritoneal sided palpation and strongly suggests peritoneal irritationirritation

Physical: Physical:

The psoas sign is determined by placing The psoas sign is determined by placing the child on the left side and the child on the left side and hyperextending the right leg.hyperextending the right leg.

Physical: Physical:

The obturator sign is determined by The obturator sign is determined by internal rotation of the flexed right thigh. internal rotation of the flexed right thigh. Pain on movement may be caused by an Pain on movement may be caused by an inflammatory mass overlying the psoas inflammatory mass overlying the psoas muscle.muscle.

Physical: Physical:

The cough sign (sharp pain in the RLQ The cough sign (sharp pain in the RLQ after a voluntary cough) is suggestive of after a voluntary cough) is suggestive of peritoneal irritation.peritoneal irritation.

Physical: Physical:

A rectal examination should be A rectal examination should be performed last and may reveal impacted performed last and may reveal impacted stool, right-sided tenderness, or a mass. stool, right-sided tenderness, or a mass. Be sure to perform a rectal examination Be sure to perform a rectal examination (inspection, palpation, and digital (inspection, palpation, and digital examination) in children who have any examination) in children who have any abdominal tenderness, a history of abdominal tenderness, a history of constipation, a history of rectal bleeding, constipation, a history of rectal bleeding, trauma, or suspected physical abuse.trauma, or suspected physical abuse.

rectal examinationrectal examination

Causes: Causes:

Most causes of appendiceal inflammation, Most causes of appendiceal inflammation, infection, and perforation begin with something infection, and perforation begin with something obstructing the appendiceal lumen. Items such obstructing the appendiceal lumen. Items such as stool, barium, food, and parasites can block as stool, barium, food, and parasites can block the lumen. Malignant tissue such as that the lumen. Malignant tissue such as that caused by carcinoid, leukemia, and lymphoma caused by carcinoid, leukemia, and lymphoma can cause tissue swelling and lumen can cause tissue swelling and lumen obstruction. obstruction.

Blunt abdominal trauma has been identified as Blunt abdominal trauma has been identified as a cause for appendicitis. a cause for appendicitis.

DIFFERENTIAL :DIFFERENTIAL :

Pancreatitis Pediatrics, Diabetic Ketoacidosis Pediatrics, Gastroenteritis Ovarian Cysts Pediatrics, Henoch-Schönlein Purpura Pediatrics, Intussusception Pediatrics, Pneumonia Pediatrics, Sickle Cell Disease Pediatrics, Urinary Tract Infections and Pyelonephritis Pelvic Inflammatory Disease Pregnancy, Ectopic Renal Calculi Testicular Torsion

Other Problems to be Other Problems to be Considered:Considered:

LymphomaLymphomaLeukemiaLeukemiaNeurogenic appendicopathyNeurogenic appendicopathyParatubal cystsParatubal cystsIntentional injury Intentional injury Sexual abuseSexual abuseTyphilitis Typhilitis

Prehospital Care:Prehospital Care:

Emergency medical service (EMS) personnel are well-Emergency medical service (EMS) personnel are well-trained and cognizant of how to assess and begin trained and cognizant of how to assess and begin treatment of the febrile, vomiting, child with abdominal treatment of the febrile, vomiting, child with abdominal pain. pain.

Intravenous fluid administration, pain management, Intravenous fluid administration, pain management, and antiemetic medication should be administered and antiemetic medication should be administered based on local EMS protocols. based on local EMS protocols.

The EMS provider must gather accurate "QRST" data The EMS provider must gather accurate "QRST" data including estimated fluid intake and loss, the child's including estimated fluid intake and loss, the child's weight gain or loss, and home remedies and weight gain or loss, and home remedies and interventionsinterventions

Emergency Department Emergency Department Care:Care:

One of the difficult challenges in evaluating children One of the difficult challenges in evaluating children with abdominal pain is making a timely diagnosis prior with abdominal pain is making a timely diagnosis prior to appendiceal perforation. In the ED, classifying to appendiceal perforation. In the ED, classifying patients with abdominal pain into the following 3 patients with abdominal pain into the following 3 categories may be helpful: categories may be helpful:

Diagnosis not consistent with appendicitisDiagnosis not consistent with appendicitis This group includes patients whose history and physical This group includes patients whose history and physical

examination are not consistent with appendicitis or any examination are not consistent with appendicitis or any significant abdominal process. significant abdominal process.

Importantly, a complete physical examination, including rectal Importantly, a complete physical examination, including rectal palpation and urinalysis, should be completed before palpation and urinalysis, should be completed before discharge from the ED.discharge from the ED.

Classic history for Classic history for appendicitisappendicitis

Patients with a classic history for appendicitis require Patients with a classic history for appendicitis require prompt surgical consultation but may not require prompt surgical consultation but may not require emergency surgery. In fact, emergency appendectomy emergency surgery. In fact, emergency appendectomy (operation within 6 h) in children has no advantages (operation within 6 h) in children has no advantages over urgent appendectomy (operation with 12 h) with over urgent appendectomy (operation with 12 h) with respect to gangrene and perforation rates, respect to gangrene and perforation rates, readmissions, postoperative complications, hospital readmissions, postoperative complications, hospital stay, or hospital charges. This does not mean the stay, or hospital charges. This does not mean the emergency physician who has made the diagnosis of emergency physician who has made the diagnosis of appendicitis will not contact the surgeon right away, but appendicitis will not contact the surgeon right away, but the hospital admission and course must be discussed the hospital admission and course must be discussed with the surgeon, patient, and familywith the surgeon, patient, and family

Antibiotic therapyAntibiotic therapy

is an important aspect of the treatment of ruptured is an important aspect of the treatment of ruptured appendicitis. Antibiotic therapy should be directed appendicitis. Antibiotic therapy should be directed against gram-negative and anaerobic organisms such against gram-negative and anaerobic organisms such as as Escherichia coliEscherichia coli and and BacteroidesBacteroides species. The species. The administration of antibiotics, nasogastric tubes, administration of antibiotics, nasogastric tubes, intravenous lines, urethral catheters, antiemetic intravenous lines, urethral catheters, antiemetic medicine, antipyretic medicine, and analgesia should medicine, antipyretic medicine, and analgesia should ideally be part of the ED protocol for managing the ideally be part of the ED protocol for managing the preoperative child. Proponents of preoperative preoperative child. Proponents of preoperative antibiotic recommend that all children with appendicitis antibiotic recommend that all children with appendicitis receive gentamicin and clindamycinreceive gentamicin and clindamycin

Unclear diagnosisUnclear diagnosis

In these children, the history may be consistent with In these children, the history may be consistent with appendicitis, while the examination is not, or the examination appendicitis, while the examination is not, or the examination may be suggestive of appendicitis in the face of an may be suggestive of appendicitis in the face of an unremarkable history. In the latter group, obtaining laboratory unremarkable history. In the latter group, obtaining laboratory studies and radiographs and reevaluating the patient over a studies and radiographs and reevaluating the patient over a few hours to determine the need for surgical consultation is few hours to determine the need for surgical consultation is helpful. helpful.

Serial examinations of the patient in the ED along with results Serial examinations of the patient in the ED along with results of the studies may help to clarify the diagnosis. of the studies may help to clarify the diagnosis.

If uncertainty persists after a period of observation, surgical If uncertainty persists after a period of observation, surgical consultation should be obtained. consultation should be obtained.

Ultrasonography may be useful when the diagnosis is Ultrasonography may be useful when the diagnosis is equivocal.equivocal.

Appendectomy is the definitive Appendectomy is the definitive treatment for appendicitis.treatment for appendicitis.

Pediatric patients with appendicitis can undergo Pediatric patients with appendicitis can undergo laparoscopic appendectomy (versus open laparoscopic appendectomy (versus open appendectomy) without incurring a greater risk for appendectomy) without incurring a greater risk for complications. complications.

Fifteen to 20% of appendectomies are performed in Fifteen to 20% of appendectomies are performed in cases for which test results are later determined to cases for which test results are later determined to be falsely positive, as appendicitis is difficult to be falsely positive, as appendicitis is difficult to diagnose in infants and toddlers.diagnose in infants and toddlers.

Nontoxic patients with a localized walled-off abscess Nontoxic patients with a localized walled-off abscess may be candidates for initial medical management may be candidates for initial medical management with antibiotics, followed by an elective with antibiotics, followed by an elective appendectomy.appendectomy.

Preoperative antibioticsPreoperative antibiotics

are given to children with suspected are given to children with suspected appendicitis and stopped after surgery if no appendicitis and stopped after surgery if no perforation exists. Patients presenting with perforation exists. Patients presenting with perforated appendicitis may be volume perforated appendicitis may be volume depleted and require aggressive fluid depleted and require aggressive fluid resuscitation. The combination of ampicillin, resuscitation. The combination of ampicillin, clindamycin, and gentamicin is administered to clindamycin, and gentamicin is administered to treat infection from aerobic and anaerobic treat infection from aerobic and anaerobic organisms. Alternative regimens include organisms. Alternative regimens include ampicillin and sulbactam, ampicillin and sulbactam,

Further Inpatient Care:Further Inpatient Care:

Laparoscopic appendectomy seems to be a safe Laparoscopic appendectomy seems to be a safe alternative for the treatment of complicated appendicitis alternative for the treatment of complicated appendicitis in children.in children. Potential advantages of laparoscopic appendectomy include Potential advantages of laparoscopic appendectomy include

reduced postoperative pain and lower wound infection rate.reduced postoperative pain and lower wound infection rate. Pediatric laparoscopic patients have fewer wound problems Pediatric laparoscopic patients have fewer wound problems

and shorter duration of oral pain and medication usage.and shorter duration of oral pain and medication usage. In addition to advantages for the patient, their parents returned In addition to advantages for the patient, their parents returned

to work quicker than parents of children who had open to work quicker than parents of children who had open appendectomy.appendectomy.

Laparoscopy can be diagnostic for alternative diagnosis in the Laparoscopy can be diagnostic for alternative diagnosis in the adolescent female.adolescent female.

LAPAROSCOPIC LAPAROSCOPIC APPENDECTOMYAPPENDECTOMY

LAPAROSCOPIC LAPAROSCOPIC APPENDECTOMYAPPENDECTOMY 2 2

Medical Pitfalls:Medical Pitfalls: Performing a complete examination including examination of the genitals Performing a complete examination including examination of the genitals

is important. Symptoms and signs of testicular torsion and ectopic is important. Symptoms and signs of testicular torsion and ectopic pregnancy overlap with appendicitis and have serious morbidity if not pregnancy overlap with appendicitis and have serious morbidity if not quickly diagnosed.quickly diagnosed.

Patients should not be diagnosed with the gastroenteritis unless they Patients should not be diagnosed with the gastroenteritis unless they have nausea, vomiting, and diarrhea. Patients with nonspecific abdominal have nausea, vomiting, and diarrhea. Patients with nonspecific abdominal complaints should be diagnosed with abdominal pain of unknown etiology. complaints should be diagnosed with abdominal pain of unknown etiology. Patients should be instructed to be reevaluated in 8-12 hours by their Patients should be instructed to be reevaluated in 8-12 hours by their primary care physician or return to the ED.primary care physician or return to the ED.

Patients with an equivocal examination should be kept for observation Patients with an equivocal examination should be kept for observation and followed-up by serial abdominal examinations. Avoid treating patients and followed-up by serial abdominal examinations. Avoid treating patients with vague abdominal pain with parenteral opiates and then discharging with vague abdominal pain with parenteral opiates and then discharging them.them.

Misdiagnosed patients were younger and more likely to have vomiting Misdiagnosed patients were younger and more likely to have vomiting before pain onset, constipation, diarrhea, dysuria, and signs and before pain onset, constipation, diarrhea, dysuria, and signs and symptoms of upper respiratory infections.symptoms of upper respiratory infections.

Misdiagnosed patients were more likely to have pain duration of more Misdiagnosed patients were more likely to have pain duration of more than 2 days, to have a temperature of more than 38.3°C, and to appear than 2 days, to have a temperature of more than 38.3°C, and to appear lethargic and irritable.lethargic and irritable.