Appendicitis (peds)
Revisión del 17:22 15 ene 2026 de Ostermayer (discusión | contribs.) (Created page with "Appendicitis (peds)")
This page is for pediatric patients. For adult patients, see: Appendicitis
Antecedentes
- La mayoría de los casos ocurren entre los 9-12 años
- La tasa de perforación es del 90% en niños menores de 4 años
- Un valor predictivo negativo (VPN) del 98% se logra si:
- Falta de náuseas (o vómitos o anorexia)
- Falta de dolor máximo en la fossa ilíaca derecha (FID)
- Falta de recuento de neutrófilos > 6750
Clinical Features
- Local tenderness + McBurney's point rigidity most reliable clinical sign
Neonates
Infants (30 days - 2 yrs)
- History
- Physical
- Diffuse abdominal tenderness
- Localized RLQ TTP occurs <50%
- Diffuse abdominal tenderness
Preschool (2 - 5yrs)
- History
- Vomiting (often precedes pain)
- Abdominal pain
- Fever
- Anorexia
- Physical
School-age (6 - 12yrs)
- History
- Vomiting
- Abdominal pain
- Fever
- Anorexia
- Physical
- RLQ tenderness
Adolescents (>12yrs)
- Present similar to adults
- RLQ pain
- Vomiting (occurs after onset of abdominal pain)
- Anorexia
Differential Diagnosis
Pediatric Abdominal Pain
0–3 Months Old
- Emergent
- Nonemergent
3 mo–3 y old
- Emergent
- Nonemergent
3 y old–adolescence
- Emergent
- Nonemergent
Evaluation
Dilated, non-compressible appendix with appendicolith and surrounding free fluid[1]
Pediatric Risk Scores
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 [2]
Alvarado Clinical Scoring System
| Dolor en el cuadrante inferior derecho | +2 |
| Temperatura elevada (37,3°C o 99,1°F) | +1 |
| Dolor de rebote | +1 |
| Migración del dolor al cuadrante inferior derecho | +1 |
| Anorexia | +1 |
| Náuseas o vómitos | +1 |
| Leucocitosis > 10.000 | +2 |
| Desplazamiento de leucocitos a la izquierda | +1 |
Sistema de puntuación clínica, donde una puntuación (Total=10) se compone de la presencia/ausencia de 3 signos, 3 síntomas y 2 valores de laboratorio para ayudar a guiar en la gestión del caso.
- ≤3 = Apendicitis poco probable
- ≥7 = Consulta quirúrgica
- 4-6 = Considerar Tomografía Computarizada (TC)
MANTRELS Mnemónico: Migración al fosa ilíaca derecha, Anorexia, Náuseas/Vómitos, Tenderness en el fosa ilíaca derecha, Rebote doloroso, Elevación de la temperatura (fiebre), Leucocitosis, y Sdesplazamiento de leucocitos a la izquierda (factores enumerados en el mismo orden que se presentan arriba).
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
- CBC
- Consider urine pregnancy test (age appropriate)
- Urinalysis
- 7-25% of patients with appendicitis have sterile pyuria
- Consider serum lactate
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 (see below) has an NPV of 99.6%[3]
- 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
- Fluid resuscitation
- IVF (20 mL/kg boluses)
- Analgesia/antiemetics (e.g., morphine, ondansetron)
- Ampicillin/sulbactam OR cefoxitin
- Penicillin allergy?
- Gentamicin + (clindamycin OR
- metronidazole)
- Perforation or complicated appendicitis[4]
- 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:
Surgery
- Surgical consult, NPO, surgical pre-op labs if appropriate
Disposition
- Admission
See Also
References
- ↑ http://www.thepocusatlas.com/pediatrics/
- ↑ 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.