Appendicitis
Bruce Minnes
Introduction
Most common nontraumatic condition requiring emergency abdominal surgery in children and adolescents
Missed appendicitis or delays to diagnosis are among the common scenarios resulting in a complaint or lawsuit regarding ED care
May present at any age, but most common in second and third decades (peak incidence 9-12 years)
˜1 in 15 lifetime risk of developing appendicitis
M:F ratio is 2:1
Incidence of perforation at diagnosis is highest in children < 1 yr (almost 100%), 94% < 2 yrs, and 60-65% < 6 yrs
Mortality rate 0.1% (nonperforated), 3-5% (perforated)
Young children can progress to perforation rapidly within 6-12 hrs from symptom onset
Need a high index of suspicion
Pathophysiology
Lumen of the appendix vermiformis becomes obstructed
Less likely in infants due to primitive shape and relative lack of lymphoid tissue in appendix
Obstruction commonly caused by
Hypertrophied lymphatic tissue: seen with viral illnesses
Fecaliths, parasites, fruit or vegetable material
Obstruction leads to venous engorgement, inflammation, and eventual necrosis and perforation
In adolescents and adults, omentum may help to “wall-off” appendicitis
Omentum less developed in young children, leading to a higher likelihood of diffuse peritonitis and increased morbidity and mortality
Clinical Presentation
Classic symptoms: abdominal pain, low-grade fever, and vomiting
Abdominal pain
Typically dull or achy at onset, later colicky, crampy, and finally constant
Initially periumbilical or epigastric, later localized to right lower quadrant as parietal peritoneum becomes irritated
Anorexia and nonbilious emesis
Some degree of fever is often present
In many cases, atypical symptoms may occur and lead to misdiagnosis
Urinary frequency and dysuria if inflamed appendix is close to the ureter and bladder
Diarrhea (frequent, small volume, and loose stools) and tenesmus (fecal urgency) may occur in retrocecal appendicitis or if appendix is near a segment of colon
Physical Examination
Resting tachycardia or fever may not be universally present, particularly in nonperforated appendicitis
May walk with slightly hunched-over gait or prefer to lie still
Pain increases with movement
Early, generalized abdominal tenderness with soft abdomen
Later: pain may localize to RLQ, maximally tender at McBurney’s point
Pain may be increased with palpation or percussion over descending colon (Rovsing’s sign)
Rebound tenderness on light palpation and involuntary guarding of the right lower quadrant may be present
Positive iliopsoas or obturator signs suggest retrocecal appendicitis:
Iliopsoas sign: pain with extension of hip
Obturator sign: painful internal rotation of hip
Digital rectal examination of limited value, may be helpful if equivocal or difficult abdominal examination (i.e., obese
patient) or in female adolescents to help to differentiate appendicitis from pelvic pathologyStay updated, free articles. Join our Telegram channel
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