ACUTE APPENDICITIS IN CHILDREN

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ACUTE APPENDICITIS IN CHILDREN

• LECTURE FROM PAEDIATRIC SURGERY DEPARTAMENT OF
  VOLGOGRAD STATE MEDICAL UNIVERSITY
• AUTOR O.I. VERBIN, ASSISTENT OF PAEDIATRIC
  SURGERY DEPARTAMENT

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POSITIONS OF APPENDIX
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PROFFERED APPENDICEAL ACTIVITIES FUNCRIONS

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

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

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Sex

• The male-to-female ratio is approximately 21.

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RISK OF DEVELOPING APPENDICITIS WITH AGE
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Age

• The mean age in the pediatric population is 6-10
  years.
• Appendicitis is rare in the neonate, and the
  diagnosis in this age group is typically made
  after perforation.
• Younger children have a higher rate of
  perforation, with reported rates of 50-85.

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Perforated appendicitis
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Mortality/Morbidity

• At the time of diagnosis, the rate of perforation
  varies from 17-40, with a higher frequency
  occurring in younger age groups.
• The mortality rate for children with appendicitis
  ranges from 0.1-1.
• Perforation increases the complication rate.

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Causes of right iliac fossa mass

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

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Causes of right iliac fossa pain

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

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CLINICAL FEATURES OF APPENDICITIS

• Central abdominal pain moving to right iliac
  fossa
• Nausea, vomiting, anorexia
• Low-grade pyrexia
• Localised tenderness in right iliac fossa
• Right iliac fossa peritonism
• Percussion tenderness is a kinder sign of
  peritonism than rebound
• Rovsing's sign pain in right iliac fossa on
  palpation of the left iliac fossa

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History

• Understanding the typical clinical manifestations
  of appendicitis is important in order to make an
  early and accurate diagnosis prior to
  perforation. The classic history of anorexia and
  periumbilical pain, followed by right lower
  quadrant (RLQ) pain and vomiting, is observed in
  fewer than 60 of patients. The clinician is more
  likely to make the diagnosis by maintaining a
  high degree of suspicion, a broad differential
  diagnosis, and looking for the atypical case
  rather than the classic appendicitis (1-2 d of
  fever, vomiting, right lower quadrant pain,
  anorexia).
• Vomiting, RLQ pain, tenderness, and guarding are
  significantly (all P less than 0.001) associated
  with appendicitis.

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History

• The initial symptom is poorly defined
  periumbilical pain, often associated with
  anorexia.
• Acute onset of severe pain is typically present
  with acute ischemic conditions, such as volvulus,
  testicular torsion, ovarian torsion, or
  intussusception.
• In appendicitis, nausea and vomiting develop
  shortly after onset of pain.
• In most cases of appendicitis, abdominal pain
  precedes vomiting.

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History

• After a few hours, the pain shifts to the RLQ due
  to inflammation of the parietal peritoneum.
• This pain is more intense, continuous, and more
  localized than the initial pain.
• This shift of pain rarely occurs in other
  abdominal conditions.

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History

• Most children with appendicitis either are
  afebrile or have a low-grade fever.
• High fever is not a common presenting feature
  unless perforation has occurred.
• Vomiting and fever are more frequent in children
  with appendicitis than in children with other
  causes of abdominal pain.

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History

• A careful family history should be obtained for
  every child in whom acute appendicitis is
  suspected.
• Multiple studies have demonstrated that children
  who have appendicitis are more than likely to
  have a positive family history.
• To date, not enough evidence exists to support a
  major gene for appendicitis. Nonetheless, a
  positive family history of appendicitis must be
  appreciated and respected when evaluating a child
  with abdominal pain.

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History

• Evaluation rules and algorithms have been
  proposed to help the clinician make the correct
  diagnosis and treatment plan. Nothing in
  emergency medicine is guaranteed, but decision
  rules can predict which children are at low risk
  for appendicitis.
• One such numerically based system is based on a
  6-part scoring system nausea (2 points), history
  of focal RLQ pain (2 points), migration of pain
  (1 point), difficulty walking (1 point), rebound
  tenderness/pain with percussion (2 points), and
  absolute neutrophil count of gt6.75 X 103/mL (6
  points).
• A score lt 5 had a sensitivity of 96.3 (95
  confidence 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,
  0.026-0.405) in the validation set.

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History

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

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History

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

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Physical

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

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Physical

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

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Physical

• A child with appendicitis typically prefers to
  lie still due to peritoneal irritation.
• Observing the child's facial expression during
  palpation of the abdomen can be helpful in
  eliciting the location and intensity of any
  abdominal pain.
• Localization of the pain depends on the position
  of the appendix.
• Typically, maximal tenderness can be found at
  McBurney point in the right lower quadrant.
• Rovsing sign is pain in the RLQ in response to
  left-sided palpation and strongly suggests
  peritoneal irritation

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Physical

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

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Physical

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

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Physical

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

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Physical

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

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rectal examination
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Causes

• Most causes of appendiceal inflammation,
  infection, and perforation begin with something
  obstructing the appendiceal lumen. Items such as
  stool, barium, food, and parasites can block the
  lumen. Malignant tissue such as that caused by
  carcinoid, leukemia, and lymphoma can cause
  tissue swelling and lumen obstruction.
• Blunt abdominal trauma has been identified as a
  cause for appendicitis.

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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

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Other Problems to be Considered

• LymphomaLeukemiaNeurogenic appendicopathyParatu
  bal cystsIntentional injury Sexual
  abuseTyphilitis

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Prehospital Care

• Emergency medical service (EMS) personnel are
  well-trained and cognizant of how to assess and
  begin treatment of the febrile, vomiting, child
  with abdominal pain.
• Intravenous fluid administration, pain
  management, and antiemetic medication should be
  administered based on local EMS protocols.
• The EMS provider must gather accurate "QRST" data
  including estimated fluid intake and loss, the
  child's weight gain or loss, and home remedies
  and interventions

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Emergency Department Care

• One of the difficult challenges in evaluating
  children with abdominal pain is making a timely
  diagnosis prior to appendiceal perforation. In
  the ED, classifying patients with abdominal pain
  into the following 3 categories may be helpful
• Diagnosis not consistent with appendicitis
• This group includes patients whose history and
  physical examination are not consistent with
  appendicitis or any significant abdominal
  process.
• Importantly, a complete physical examination,
  including rectal palpation and urinalysis, should
  be completed before discharge from the ED.

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Classic history for appendicitis

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

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Antibiotic therapy

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

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Unclear diagnosis

• In these children, the history may be consistent
  with appendicitis, while the examination is not,
  or the examination may be suggestive of
  appendicitis in the face of an unremarkable
  history. In the latter group, obtaining
  laboratory studies and radiographs and
  reevaluating the patient over a few hours to
  determine the need for surgical consultation is
  helpful.
• Serial examinations of the patient in the ED
  along with results of the studies may help to
  clarify the diagnosis.
• If uncertainty persists after a period of
  observation, surgical consultation should be
  obtained.
• Ultrasonography may be useful when the diagnosis
  is equivocal.

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Appendectomy is the definitive treatment for
appendicitis.

• Pediatric patients with appendicitis can undergo
  laparoscopic appendectomy (versus open
  appendectomy) without incurring a greater risk
  for complications.
• Fifteen to 20 of appendectomies are performed in
  cases for which test results are later determined
  to be falsely positive, as appendicitis is
  difficult to diagnose in infants and toddlers.
• Nontoxic patients with a localized walled-off
  abscess may be candidates for initial medical
  management with antibiotics, followed by an
  elective appendectomy.

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Preoperative antibiotics

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

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Further Inpatient Care

• Laparoscopic appendectomy seems to be a safe
  alternative for the treatment of complicated
  appendicitis in children.
• Potential advantages of laparoscopic appendectomy
  include reduced postoperative pain and lower
  wound infection rate.
• Pediatric laparoscopic patients have fewer wound
  problems and shorter duration of oral pain and
  medication usage.
• In addition to advantages for the patient, their
  parents returned to work quicker than parents of
  children who had open appendectomy.
• Laparoscopy can be diagnostic for alternative
  diagnosis in the adolescent female.

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LAPAROSCOPIC APPENDECTOMY
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LAPAROSCOPIC APPENDECTOMY 2
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Medical Pitfalls

• Performing a complete examination including
  examination of the genitals is important.
  Symptoms and signs of testicular torsion and
  ectopic pregnancy overlap with appendicitis and
  have serious morbidity if not quickly diagnosed.
• Patients should not be diagnosed with the
  gastroenteritis unless they have nausea,
  vomiting, and diarrhea. Patients with nonspecific
  abdominal complaints should be diagnosed with
  abdominal pain of unknown etiology. Patients
  should be instructed to be reevaluated in 8-12
  hours by their primary care physician or return
  to the ED.
• Patients with an equivocal examination should be
  kept for observation and followed-up by serial
  abdominal examinations. Avoid treating patients
  with vague abdominal pain with parenteral opiates
  and then discharging them.
• Misdiagnosed patients were younger and more
  likely to have vomiting before pain onset,
  constipation, diarrhea, dysuria, and signs and
  symptoms of upper respiratory infections.
• Misdiagnosed patients were more likely to have
  pain duration of more than 2 days, to have a
  temperature of more than 38.3C, and to appear
  lethargic and irritable.

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