Critical Care Medicine

Gastrointestinal Emergencies: Appendicitis

Also known as: Acute Appendicitis

1. Description of the problem

What every clinician needs to know

Acute appendicitis in children is similar to that in adults. Children often have less right lower quadrant (RLQ) pain than adults and may have more vomiting. Otherwise, the typical presentation is similar, with abdominal pain, anorexia, vomiting, fever, and abdominal tenderness with guarding. Children under the age of two may have more diffuse abdominal tenderness and cannot often locate pain; however, appendicitis in children under the age of 2 is relatively uncommon.

Clinical features

RLQ abdominal pain

Anorexia

Nausea and vomiting

Abdominal tenderness with guarding

Key management points

The management of acute appendicitis in children remains surgical, with emphasis on early diagnosis.

Analgesia - Use of IV analgesics should not be avoided in evaluation of acute appendicitis as multiple studies have shown it does not mask clinical symptoms that would indicate acute appendicitis requiring surgical treatment.

IV Hydration - Many children presenting with acute appendicitis may have had a decreased intake over the previous 2-3 days and may be more dehydrated than they initially appear, especially in the face of vomiting. Aggressive IV hydration is suggested early in evaluation.

Antibiotic Prophylaxis - Use of antibiotic prophylaxis is suggested to reduce wound infection and abscess formation.

Surgical Treatment - The mainstay of acute appendicitis remains surgery. Laparoscopic appendectomy is the preferred approach as it is associated with a decreased hospital stay and decreased risk of wound infection.

2. Emergency Management

1. Fluid Hydration - Due to decreased intake and vomiting, sometimes for multiple days, aggressive fluid hydration is suggested during the evaluation process for acute appendicitis.

2. Early Surgical Consultation - Early surgical treatment is suggested.

3. IV Analgesia

4. Laboratory Evaluation

3. Diagnosis

1. Physical Examination - Physical examination in children, especially younger children, can be difficult. Children often will lie still and often in the fetal position with their hips flexed. More subtle findings are often present if the appendix is located posteriorly. Often rebound tenderness as well as abdominal pain with cough can be the initial physical exam findings before more generalized abdominal tenderness or peritoneal signs develop. Classic signs have been taught throughout generations and are still applicable today, including:

Iliopsoas sign - pain on extension of the right hip

Obturator sign - pain on internal rotation of the right hip

Rovsing's sign - pain on palpation of the left side

2. Laboratory Evaluation

WBC - The WBC and/or neutrophil count are often elevated, although this is non-specific and can often be seen in other conditions within the differential diagnosis of acute appendicitis.

CRP - The CRP is often elevated but again is not sensitive to appendicitis.

3. Diagnostic Imaging

Ultrasound is readily available and inexpensive and does not expose children to ionizing radiation and thus should be considered the first imaging test in suspected acute appendicitis, depending on the skill and experience at the institution.

Computed tomography (CT) is more sensitive and specific than ultrasound but exposes children to ionizing radiation and may not visualize the appendix. Oral, IV and rectal contast can often help the accuracy of CT imaging for appendicitis.

Differential diagnosis

The differential diagnosis of acute appendicitis includes other abdominal and/or pelvic conditions that include abdominal pain, diarrhea, and vomiting. The differential diagnosis is thus broad but includes the following:

Gastroenteritis

Nephrolithiasis

Ectopic Pregnancy or Pelvic Inflammatory Disease

Testicular or Ovarian Torsion

Intussusception

4. Specific Treatment

Once diagnosed, the treatment for acute appendicitis is surgical in nature.

Pathophysiology

The appendix is located in the right lower quadrant of the abdomen in the cecum and may lie in the retrocecal/retroileal position or in the typical pelvic position. Appendicitis is believed to be caused by an obstruction of the appendiceal lumen resulting in bacterial overgrowth of typical bowel flora, inflammation and ultimately ischemia and perforation. The inflamed appendix itself may not cause severe pain but can cause irritation of the overlying peritoneal wall, causing localization of the pain to the RLQ.

Epidemiology

Appendicitis is the most common reason for emergent abdominal surgery in childhood and often presents in the second decade of life. It is less common in children under the age of 6. Perforation is more common if symptoms have been present for more than 72 hours.

Prognosis

Prognosis after surgical therapy is excellent, without long-term complications.

Perforation of the appendix causes short-term morbidity with prolonged hospital stay, prolonged antibiotic use, and the potential for abdominal scarring, but long-term prognosis is excellent, without significant complications.

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