Appendicitis in Children

1
Appendicitis in Children

• Adela T. Casas-Melley, MD, FACS, FAAP
• Chief, Pediatric Surgery
• Sanford Childrens Specialty Clinic
• Sanford USD Medical Center

2
Objectives

• Review the pathophysiology of appendicitis in
  children
• Discuss the diagnosis of appendicitis
• Differentiate between acute and perforated
  appendicitis
• Identify treatment options for pediatric
  appendicitis

3
History

• First mention 500 years ago
• Appendicitis suspected in 1827
• Fitz coins appendicitis in 1886
• First appendectomy 1735
• Amyand - Scrotal abscess
• First deliberate appendectomy in USA in 1887 for
  perforated appendicitis
• McBurney does appendectomy before rupture in 1889
• Describes point of maximal pain
• McBurneys Point

4
Embryology Anatomy

• First visible during week 8
• Position variable
• Intraperitoneal 95
• In pelvis 30
• Behind cecum 65
• Retroperitoneal 5
• Always arises at junction of teniae coli
• Function Unknown
• Primates and rabbits only mammals to have appendix

5
Appendicitis

• Most likely caused by luminal obstruction
• Inspisated fecal material
• Ingested foreign body
• Parasites
• Lymphoid hyperplasia

6
Pathophysiology

• Most likely caused by luminal obstruction
• Mucous production
• Bacterial proliferation
• Increased intraluminal pressure
• Impaired lymphatic and venous drainage
• Compromised arterial inflow
• Tissue Ischemia
• Necrosis
• Perforation

7
Incidence

• Most common cause of acute surgical abdomen in
  children
• Lifetime risk
• 8.67 for boys
• 6.7 for girls
• Peak Incidence between 12 and 18 years
• Rare under the age of 5
• Genetic predisposition, especially in children
  with appendicitis before age 6

8
Significance

• In the USA, 70,000 children annually diagnosed
  with appendicitis
• 1 per 1000 children per year
• 630 million charges

9
Diagnosis

• Best made with careful history and physical
• Often deviates from classic description
• Differential diagnosis varies with age of child

10
Classic Description

• Anorexia, then vague periumbilical pain
• Pain migrates to Right Lower Quadrant
• Nausea and Vomiting follow pain
• Diarrhea may occur
• Fever, if present, is low grade
• Appendix commonly ruptures 24-48 hours after
  onset of symptoms

11
Physical Exam

• Tenderness near McBurney's point
• Retrocecal appendix or obese children, and some
  ethnic groups may have less tenderness
• Psoas sign
• Obturator sign
• Rovsing's sign
• Digital rectal exam useless in evaluation of
  appendicitis in children
• Mass in RLQ may be missed if guarding

12
Differential Diagnosis

• Constipation
• Gastroenteritis
• Mesenteric adenitis
• Pneumonia
• Meckels Diverticulitis
• Inflammatory Bowel Disease
• Cholecystitis
• Pancreatitis
• Typhlitis
• Urinary tract infection
• Pelvic inflammatory disease
• Ovarian pathology (tumor, torsion)

13
Constipation

• Most frequent cause of abdominal pain in children
• Most common reason children present to the
  emergency room
• Symptoms may be indistinguishable from
  appendicitis
• Abdominal x-ray may demonstrate fecal loading
• Dietary modifications, medications

14
Mesenteric Adenitis

• Abdominal lymphadenitis secondary to viral
  illness
• Acute swelling of lymph nodes in mesentery causes
  abdominal pain
• Highest concentration of lymph nodes near
  terminal ileum
• Symptoms may be indistinguishable from
  appendicitis
• Self-limiting

15
Pneumonia

• RLL pneumonia may present as abdominal pain,
  especially in younger children
• Fever, leukocytosis, abdominal pain in child lt5
  years old should be evaluated for pneumonia
• Symptoms may be indistinguishable from
  appendicitis

16
Meckels Diverticulum

• Rule of 2s
• 2 population
• 2 feet from ileocecal valve
• 2 types of ectopic mucosa
• Should be suspected in children with negative
  exploration for appendicitis

17
Back to Appendicitis
18
Laboratory studies

• Leukocyte count
• Usually mildly elevated (11-16,000)?
• Markedly elevated perforated appendicitis or
  alternative diagnosis
• Urinalysis
• Free of bacteria, may have few RBC or WBC
• Usually concentrated with ketones
• Electrolytes/LFTs
• Normal

19
Imaging

• Plain films
• Sentinel loops (localized ileus)?
• Mild scoliosis (Psoas spasm)?
• Fecolith (10-15 perforated appendicitis)?
• Low sensitivity not recommended

20
Imaging

• Ultrasound
• Specificity 90, Sensitivity 50-92
• Normal appendix must be seen to exclude
  appendicitis
• Positive criteria
• Noncompressible tubular structure 6mm or greater
• Complex mass in RLQ
• Fecolith

21
Imaging

• CT scan
• gt95 sensitivity and specificity
• Thickened appendix
• Periappendiceal fat stranding
• Fecalith
• Abscess or phlegmon

22
CT scans

• Highly accurate, but are they necessary?
• More expensive than ultrasound
• May require contrast administration
• Exposure to ionizing radiation
• One CT equivalent to 100 plain abdominal films
• Single CT scan carries average 1/1000 lifetime
  mortality risk from radiation-induced malignancy
• Imaging has not changed negative appendectomy rate

23
Care Algorithm

• History and Physical
• If classic - no need for imaging
• If equivocal - may proceed with imaging or
  observation
• U/S first choice, except in obese or likely other
  dx
• Best choice to image ovaries
• Diagnostic accuracy improved with repeat exams
  and labs over 12 to 24 hours
• Fewer than 2 of appendixes will rupture while
  under observation

24
Treatment

• Intravenous fluids
• Antibiotics
• Appendectomy
• Non-operative therapy may be considered for those
  with perforated appendicitis
• Children who fail to improve in 24-72 hours will
  need appendectomy
• High failure rate if significant bandemia in
  differential

25
Treatment

• Immediate vs. Delayed Appendectomy
• No need to operate in middle of night with
  hemodynamically stable child with appendicitis
• No change in perforation rate or complications
• Findings seem to be more indicative of initial
  presentation

26
Treatment

• Interval Appendectomy
• Employed 6 weeks after non-operative treatment
  for perforated appendicitis
• Risk of recurrent appendicitis may be 15
• Others claim risk not as high and interval
  appendectomy is unnecessary

27
Treatment

• Laparoscopic vs. Open Appendectomy
• Laparoscopy proven at least equivalent, if not
  superior to open appendectomy
• Post-op course related more to severity of
  appendicitis than to procedure performed
• Cosmesis much improved

28
Evolution
29
Single Site Surgery

• When compared to standard laparoscopy
• No change in operative time
• Similar post-op analgesia
• No significant complications
• Excellent cosmesis

30
Treatment

• Post-operative course dictated by operative
  findings
• Montreal Protocol
• Simple Appendicitis
• Preoperative dose of antibiotics
• Discharge home POD1
• No additional antibiotics
• Complicated (Perforated or Gangrenous)
  Appendicitis
• Intravenous antibiotics for at least 48 hours
• Antibiotics continue as long temperature spikes
  above 37.5C
• When afebrile for gt24hrs, check WBC
• if WBCgt10, home on oral antibiotics
• if WBClt10, home without antibiotics

31
Summary

• Appendicitis is a common cause of abdominal pain
  in children
• A careful history and physical can reliably make
  diagnosis in majority of cases
• Minimally invasive appendectomy is treatment of
  choice
• Post-operative management is determined by
  operative findings

32
Assessing the Pediatric Trauma Patient What
imaging is enough

• Adela T. Casas-Melley, MD, FACS, FAAP
• Chief, Pediatric Surgery
• Sanford Childrens Hospital
• Assistant Medical Director Trauma Service

33
Objectives

• Describe the appropriate imaging of the pediatric
  trauma patient
• Evaluate the risks of certain imaging modalities
  and establish criteria for imaging decision
  making
• Discuss the likelihood of pediatric spine
  injuries and the need for imaging
• List different modalities for abdominal
  evaluation of the pediatric trauma patient

34
Case 1

• 11 YO female who was trying to go from one fort
  to another via a zip line and her hand slipped
  and she fell 18 feet to the ground.
• She landed on her feet and crumpled to the
  ground.
• She denies hitting her head, denies loss of
  consciousness. Remembers the entire accident
• Her only complaint is left ankle pain.

35
Case 1

• She was evaluated at outside institution and had
• CT of head negative
• CT of C-spine negative
• CT of T-spine negative
• CT of L-spine negative
• CT of abdomen negative
• No plain films obtained
• What are the consequences of all of these studies?

36
Radiation Exposure in X-rays
37
Background Radiation
38
Exposure to this Child

• Equivalent of 300 CXRs in one day
• Equivalent to 8 years and 8 months of background
  radiation exposure
• In a child with no complaints of injury.

39
Case 2

• 2 YO Male who fell through a register
  approximately 9 to 10 feet on to a hard wood
  floor.
• Cried immediately, complained of headache
• Became a little somnolent and ended up intubated
• Prior to transfer CT scans obtained

40
Case 2

• Following studies obtained
• CT of head left occipital skull fracture
• CT of C-spine negative
• CT chest negative
• CT abdomen and pelvis negative
• No plain films obtained
• CT chest, abdomen and pelvis obtained without
  contrast

41
Radiation exposure

• Equivalent to 250 CXRs in a 2 YO child that is
  highly sensitive
• CT of chest abdomen and pelvis obtained without
  contrast so they are truly useless.
• Do not have anyone available that can respond to
  data so why delay transfer to get it
• Let the referring physician decide what studies
  they need

42
CT An Increasing Source of Radiation Exposure

• Since 1970s CT use had increased to about 62
  million CTs a year
• 4 million CTs in children
• Major growth has been driven by decrease time for
  CT
• CT contributes disproportionally to radiation
  dose to population
• 4 of test 40 of radiation

43
Radiation Exposure

• Pediatrics represents small fraction of tests
• But fraction is increasing
• Combination of higher radiation dose and larger
  lifetime risk results in a significantly higher
  lifetime cancer mortality risk.
• Lifetime risk attributable to single dose is
  larger in children

44
Lifetime Radiation-Induced Risk of Cancer
45
Radiation Risks

• Calculated risk based on atomic bomb radiation
  patients
• Extrapolated data to determine organ exposure
  based on age at exposure
• On basis of number of scans done and age
  distribution, the lifetime mortality risks are
  calculated

46
Radiation Risks

• Predicted total numbers of deaths attributable to
  1 year of CT exams in the US are
• 700 for head CT
• 1800 for CT abdomen and pelvis
• Children account for
• 170 for head CT
• 310 for CT abdomen and pelvis

47
Radiation Risks

• Childhood CT examinations contribute
  significantly to overall estimate
• Pediatric CT exams make up only 4 of total test
  but contribute 20 of total deaths
• Lifetime cancer risk of a 1 year old from one CT
  of abdomen and pelvis is 1 in 550
• 1 in 1500 for head CT

48
Radiation Risk

• If you take 600,000 as average number of CTs
  done in children under 15
• 500 children will ultimately die from the CT scan
  they received
• Weigh the risk benefit ration
• Use alternatives when possible

49
Part of the problem

• Physicians view CT studies in same light as other
  X-rays
• Recent survey of radiologist and ER physicians
  75 underestimated radiation dose from CT
• 53 of radiologist and 91 of ER physicians did
  not believe CT increased lifetime risk of cancer

50
3 Ways to reduce exposure

• Reduce the CT dose We are lucky to have the
  first CT scanner with software to reduce
  radiation exposure by 45
• Replace CT when possible Ultrasound is a very
  good viable alternative for trauma evaluation in
  children
• Simply decrease the number of CTs ordered

51
Do you really need that CT?

• Despite the fact that most CT scans are
  associated with favorable ratios of benefit to
  risk there is strong evidence that too many are
  being done
• CT evaluation for blunt trauma
• Practice of defensive medicine
• Repeat CTs (head injuries, solid organ injuries)
• Repeat because of lack of communication

52
Impact of CT on patient management in blunt trauma

• Recent study evaluated 1500 consecutive children
  with blunt abdominal trauma
• CT findings and decision for operative or non
  operative management were recorded
• 388 (26) of CT scans had abnormal findings
• 286 solid organ
• 103 other
• 30 hollow viscous injury

53
Impact of CT on patient management in blunt trauma

• 20 of the 286 (7) of solid organ injury and 25
  of 30 (83) of hollow viscous injury children
  underwent surgery
• Injury was confirmed in all children with solid
  organ injury and 24 of 25 children with hollow
  viscous injury
• Decision for surgery was based on CT findings in
  25 of solid organ injury and 68 of hollow
  viscous injury
• But, 74 of children had negative CTs

54
Alternatives

• Focused assessment of sonography for trauma
  (FAST) Evaluates free fluid around the heart
  and three areas of the abdominal-pelvic cavity
• RUQ Between liver and kidney (Morrisons pouch)
• LUQ Between spleen and kidney
• Subxiphoid area pericardial sac
• Suprapubic areas behind bladder in males,
  uterus in females

55
Alternatives

• Extended version of FAST (E-FAST) involves
  evaluating anterior chest for pneumothorax
• Can determine if there is free fluid in abdomen
  or pericardium in unstable patient to direct
  intervention.
• Does have limitations. Does not evaluate
  retroperitoneum or hollow viscous
• Convenient, portable

56
Alternatives

• Use well documented in adults. Less clear in
  pediatrics
• Very specific to detect hemoperitoneum but less
  sensitive to define positive study
• However, negative ultrasound and negative exam
  virtually excludes injury.
• Can use FAST to guide need for CT

57
Evaluation of the pediatric spine

• NEXUS criteria have been out for many years but
  have not been consistently used in pediatric
  patients
• Consist of deciding if patients need X-rays if
  they show the following
• Midline cervical tenderness
• Focal neurologic deficits
• Altered mental status
• Evidence of intoxication
• Painful distracting injury

58
Evaluation of the pediatric spine

• NEXUS has been validated multiple times and
  compared to several other methods with good
  results
• Sensitivity 99
• Specificity 99
• Is the NEXUS criteria valid in children?

59
Evaluation of the pediatric spine

• Prospective multicenter study done in pediatric
  blunt trauma patients (lt18 YO)
• Patient had NEXUS criteria applied during
  evaluation
• Decision to do films was at MDs discretion and
  not driven by NEXUS but NEXUS criteria were
  documented
• Presence or absence of injury based on final
  interpretation of X-rays

60
Evaluation of the pediatric spine

• 3065 patients evaluated
• 30 patients (0.98) had injury documented
• Study included
• 88 children under 2
• 817 between 2 and 8
• 2160 between 8 and 17

61
Evaluation of the pediatric spine

• 45.9 of injuries were of the lower cervical
  spine
• No cases of SCIWORA
• Only 4 of 30 injured children were younger than 9
• None under 2
• Most common finding were tenderness and
  distracting injury

62
Evaluation of the pediatric spine

• NEXUS correctly identified all pediatric patients
  with injury
• Sensitivity 100
• Correctly designated 603 patients as low risk
• Negative predictive value 100

63
Evaluation of the pediatric spine

• Conclusions
• Lower cervical spine most common site of injury
• Injury very rare in children under 8
• NEXUS performed well and its use could reduce
  20 of c-spine films
• No single case in literature of occult injury in
  child classified as low risk by NEXUS
• All patients with injury report pain, have
  neurologic findings, or have altered mental
  status and get studies

64
CT versus plain films

• Study to determine value of CT of spine in
  children under 5
• 606 patients having cervical spine evaluation in
  the ER
• Documented age and sex as well as exam findings
  and presence of injury on plain films and CT

65
CT versus plain films

• Of the 606 patients studies
• 459 (75.7) were cleared by combination of exam,
  and plain films
• 147 (24.3) went on to CT imaging for clearing of
  the cervical spine
• Of the 147 who had CT
• 143 (97.3) were negative
• 4 (2.7) were positive. All of these patients
  had positive findings on plain films

66
CT versus plain films

• The yield of CT of the spine in children under 5
  was very low and all patients had the same
  finding of plain films.
• CT of the spine is equal to 60 CXR and 4 C-spine
  series
• Is it worth the risk?

67
CT versus plain films

• A study to evaluate the radiation exposure of
  children who had CT of the c-spine was done in
  Atlanta.
• Retrospective review of all children who had CT
  of the spine in the ER after trauma
• 992 children were evaluated
• Only 181 (18) had prior C-spine series

68
CT versus plain films

• Divided the study into three groups
• 0-4 YO
• 5-8 YO
• gt8 YO
• They used anthropomorphic dosimetry phantoms for
  group 1 and 2

69
CT versus plain films

• Evaluated exposure for C-spine series
• Series 1 lateral
• Series 2 Four views
• Series 3 - Seven views
• Evaluated exposure for CT
• CT head
• CT C-spine

70
CT versus plain films

• They calculated radiation exposure of the
  phantoms and then retrospectively calculated the
  radiation exposure of the children in the study
• They then calculated a relative risk of thyroid
  cancer based on comparison of previous study of
  children exposed to radiation in the 50s for
  treatment of tinea capitis

71
CT versus plain films

• Results showed
• 992 patients
• 435 had C-spine x-rays only
• 181 had C-spine and CT
• 376 had CT only
• Radiation dose for CT of the C-spine
• Group 1 200X more than from C-spine series
• Group 2 90X more than from C-spine series

72
CT versus plain films

• Relative risk for developing thyroid cancer
• Group 1 none from conventional C-spine series
• Group 1 relative risk from CT head was 0.03 but
  relative risk of 2 for CT of C-spine
• Group 2 no increase from C-spine series
• Group 2 relative risk from CT head 0.02 but
  increased to 0.07 for CT C-spine

73
What alternatives do we have

• Evaluate the patient and determine if there is
  need for radiologic studies
• Do not get studies because of a knee jerk
  decision of what is done on all trauma patients
• Evaluation of children can be very difficult. If
  you think the child has significant injuries and
  you are unable to get a good exam or feel
  uncomfortable, send them to someone with
  experience

74
What alternatives do we have

• Get baseline studies first
• Do not scan head to toe, rarely ever needed
• Use alternative studies when you can
• Never delay transfer to another institution to
  get scans. The accepting docs will determine
  what they need. Stabilize and send
• If you do get CT, please use contrast so we can
  actually use data

75
What about C-spine

• Evaluate patient and determine NEXUS criteria
• Calm the child down and do a physical exam
• Obtain plain films first
• If you feel you need a CT by all means get it,
  but do not get it because it is a child and you
  feel uncomfortable with the exam.
• You still need an exam before clearing the spine
  anyway. A negative CT does not clear the spine

76
Imaging of the pediatric trauma patient

• Hope this data has made you think about how many
  children we are exposing to risky doses of
  radiation
• This also applies to evaluation of the pediatric
  patient for abdominal pain

77

• Questions
• ?