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Key Features

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Essentials of Diagnosis
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  • Fever

  • Periumbilical abdominal pain

  • Anorexia, vomiting, constipation, and diarrhea

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General Considerations
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  • Most common indication for emergency abdominal surgery in childhood

  • Frequency increases with age and peaks between 15 and 30 years

  • Causes

    • Idiopathic

    • Obstruction of the appendix by fecalith is common predisposing factor

    • Parasites may rarely cause obstruction (especially ascarids)

  • Incidence of perforation is high in childhood (40%), especially in children younger than 2 years, in whom pain is often poorly localized and symptoms nonspecific

  • To avoid delay in diagnosis, perform a thorough initial physical examination with sequential examinations at frequent intervals over several hours to correctly interpret the evolving symptoms and signs

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Clinical Findings

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Symptoms and Signs
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  • Fever

  • Periumbilical abdominal pain, which then localizes to the right lower quadrant with signs of peritoneal irritation

  • Anorexia, vomiting (follows onset of pain; often bilious), constipation, and diarrhea

  • Clinical picture is frequently atypical, especially in young children and infants

  • Rectal examination may clarify the site of tenderness or reveal a localized appendiceal mass

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Differential Diagnosis
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  • Pneumonia

  • Pleural effusion

  • Urinary tract infection

  • Right-sided kidney stone

  • Cholecystitis

  • Perihepatitis

  • Pelvic inflammatory disease

  • Acute gastroenteritis with Yersinia enterocolitica may present as pseudoappendicitis in 17% of cases

  • Other medical and surgical conditions causing acute abdomen

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Diagnosis

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Laboratory Findings
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  • White blood cell count is seldom higher than 15,000/μL

  • Pyuria, fecal leukocytes, and guaiac-positive stool are sometimes present

  • Combination of elevated C-reactive protein (CRP) and leukocytosis

    • Have positive predictive value of 92%

    • However, normal values do not exclude the diagnosis

  • Levels of interleukin 6 (IL-6)

    • Show promise as a potential biomarker

    • Usually peaks within 24 hours of onset of pain

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Imaging
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  • A radio-opaque fecalith is present in two-thirds of cases of ruptured appendix

  • Ultrasonography shows a noncompressible, thickened appendix in 93% of cases

  • Abdominal CT after rectal instillation of contrast may be diagnostic

  • An otherwise normal abdominal CT scan with a nonvisualized appendix has been reported to have a negative predictive value of 99%

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Treatment

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  • Exploratory laparotomy or laparoscopy is indicated when the diagnosis of acute appendicitis cannot be ruled out after a period of close observation

  • Postoperative antibiotic therapy is reserved for patients with gangrenous or perforated appendix

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Outcome

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Prognosis
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  • Mortality rate is < 1% during childhood, despite the high incidence of perforation

  • In uncomplicated nonruptured appendicitis, a laparoscopic approach is associated with a shortened hospital stay

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References

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Bansal  S, Banever  GT, Karrer  FM, Partrick  DA: Appendicitis in children less than 5 years old: influence of age on presentation and outcome. Am J Surg 2012 Dec;204(6):1031–1035
[PubMed: 23231939] .
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Kharbanda  AB  et al: Discriminative accuracy of novel and traditional biomarkers ...

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