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{{PediatricPage|Appendicitis}}

==Background==

[[File:Appendix locations.png|thumb|Drawing of colon with variability of appendix locations as seen from anterior view.]]
*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==

[[File:McBurney's point.jpg|thumb|Location of McBurney's point (1), located two thirds the distance from the umbilicus (2) to the right anterior superior iliac spine (3).]]
*Local tenderness + McBurney's point rigidity most reliable clinical sign

===Neonates===

*History
**[[Special:MyLanguage/Nausea and vomiting (peds)|Vomiting]]
**Irritability/[[Special:MyLanguage/altered mental status (peds)|lethargy]]
*Physical
**Abdominal distention

===Infants (30 days - 2 yrs)===

*History
**[[Special:MyLanguage/Nausea and vomiting (peds)|Vomiting]]
**[[Special:MyLanguage/Abdominal pain (peds)|Abdominal pain]]
**[[Special:MyLanguage/Fever (Peds)|Fever]]
*Physical
**Diffuse abdominal tenderness
***Localized RLQ TTP occurs <50%

===Preschool (2 - 5yrs)===

*History
**[[Special:MyLanguage/Nausea and vomiting (peds)|Vomiting]] (often precedes pain)
**[[Special:MyLanguage/Abdominal pain (peds)|Abdominal pain]]
**[[Special:MyLanguage/Fever (Peds)|Fever]]
**Anorexia
*Physical
**[[Special:MyLanguage/RLQ tenderness|RLQ tenderness]]


===School-age (6 - 12yrs)===

*History
**[[Special:MyLanguage/Nausea and vomiting (peds)|Vomiting]]
**[[Special:MyLanguage/Abdominal pain (peds)|Abdominal pain]]
**[[Special:MyLanguage/Fever (Peds)|Fever]]
**Anorexia
*Physical
**RLQ tenderness


===Adolescents (>12yrs)===

*Present similar to adults
**RLQ pain
**[[Special:MyLanguage/Vomiting|Vomiting]] (occurs after onset of abdominal pain)
**Anorexia


==Differential Diagnosis==

{{Pediatric abdominal pain DDX}}


==Evaluation==

[[File:Appendicitis_Jarrett_Subramaniam.gif|thumbnail|Dilated, non-compressible appendix with appendicolith and surrounding free fluid<ref>http://www.thepocusatlas.com/pediatrics/</ref>]]
[[File:AppendicitisMark.png|thumb|Peri-appendiceal fat stranding in the setting of acute appendicitis.]]
[[File:X-ray showing fecalith which has caused appendicitis.jpg|thumb|Fecalith (arrow) and stranding in the setting of acute appendicitis.]]
[[File:CAT scan demonstrating acute appendicitis.jpg|thumb|Dialated appendix and stranding in the setting of acute appendicitis.]]

===Pediatric Risk Scores===


====Pediatric Appendicitis Score====

{| class="wikitable"
| 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 <ref>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</ref>

{{Alvarado scoring system}}


===Workup===


====Laboratory Findings====

*Abdominal panel
**CBC
***<10K is a negative predictor of appendicitis
***However, normal WBC does not rule-out appendicitis
**Chemistry
**Consider LFTs + lipase
**Consider coagulation studies (PT, PTT, INR), as a marker of liver function
*Consider urine pregnancy test (age appropriate)
*[[Special:MyLanguage/Urinalysis|Urinalysis]]
**7-25% of patients with appendicitis have [[Special:MyLanguage/sterile pyuria|sterile pyuria]]
*Consider [[Special:MyLanguage/serum lactate|serum lactate]]


====Imaging====

''Consider in intermediate or higher risk patients''
*[[Ultrasound: Abdomen|Ultrasound]]
**Sn: 88%, Sp: 94%
**Consider as 1st choice in non-obese children
**Indeterminate [[Special:MyLanguage/ultrasound|ultrasound]] and an Alvarado <5 (see below) has an NPV of 99.6%<ref>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.</ref>
*CT with IV contrast
**Sn: 94%, Sp: 95%
**Consider if ultrasound is equivocal '''OR''' strong suspicion despite normal ultrasound


===Diagnosis===

*Patients can be ruled out via a combination of history, physical, labs, and imaging.
*Confirmatory diagnosis is typically made on imaging
*Ultrasound is typically performed first:
**If appendix is positive, appendicitis is ruled in
**If appendix is visualized and negative, appendicitis is ruled out
**If appendix is unable to be visualized (i.e., indeterminant), then post-test probability is unchanged. Re-examine and consider CT as next diagnostic study.


==Management==


===Supportive Management===

*NPO status
*[[Special:MyLanguage/Fluid resuscitation|Fluid resuscitation]]
**[[Special:MyLanguage/IVF|IVF]] (20 mL/kg boluses)
*[[Special:MyLanguage/Analgesia|Analgesia]]/[[Special:MyLanguage/antiemetics|antiemetics]] (e.g., [[Special:MyLanguage/morphine|morphine]], [[Special:MyLanguage/ondansetron|ondansetron]])


===[[Special:MyLanguage/Antibiotics|Antibiotics]]===

*[[Special:MyLanguage/Ampicillin/sulbactam|Ampicillin/sulbactam]] '''OR''' [[Special:MyLanguage/cefoxitin|cefoxitin]]
*Penicillin allergy?
**[[Special:MyLanguage/Gentamicin|Gentamicin]] + ([[Special:MyLanguage/clindamycin|clindamycin]] '''OR'''
**[[Special:MyLanguage/metronidazole|metronidazole]])
*Perforation or complicated appendicitis<ref>Yardeni D et al. Single daily dosing [[Special:MyLanguage/ceftriaxone|ceftriaxone]] and [[Special:MyLanguage/metronidazole|metronidazole]] vs standard triple antibiotic regimen for perforated appendicitis in children: a prospective randomized trial. J Pediatr Surg. 2008 Jun; 43(6): 981–985.</ref>
**IV antibiotic regimen as below:
***[[Special:MyLanguage/Ampicillin|Ampicillin]] 100 mg/kg/d q6hr, max 8 g per dose '''AND'''
***[[Special:MyLanguage/Gentamicin|Gentamicin]] 5 mg/kg QD, max 300 mg '''AND'''
***[[Special:MyLanguage/Metronidazole|Metronidazole]] 30 mg/kg/d q8hr, max 1.5 g
**Daily doses of [[Special:MyLanguage/ceftriaxone|ceftriaxone]] and [[Special:MyLanguage/metronidazole|metronidazole]] just as effective:
***[[Special:MyLanguage/Ceftriaxone|Ceftriaxone]] 50 mg/kg, max 2 g QD '''AND'''
***[[Special:MyLanguage/Metronidazole|Metronidazole]] 30 mg/kg, max 1.5 g QD


===Surgery===

*Surgical consult, NPO, surgical pre-op labs if appropriate


==Disposition==

*Admission


==See Also==

*[[Special:MyLanguage/Abdominal pain (peds)|Abdominal pain (peds)]]


==References==

<references/>

[[Category:Pediatrics]]
[[Category:Surgery]]
[[Category:ID]]