Acute Appendicitis

8 y/o pt presents with acute onset abdominal pain. Pain started 24 hours ago in periumbilical region with radiation to RLQ. Pain now localized in RLQ and worse with coughing, movement. Reports anorexia, N/V. Fever, decreased bowel sounds, abdominal rigidity/guarding, RLQ pain with rebound tenderness on exam; positive psoas, obturator, and Rovsing signs.

• Labs

  • CBC shows leukocytosis (WBC >10,000) with left shift (ANC >7,500)

  • Obtain CMP, CRP

  • Consider obtaining APPY1 panel, U/A, and/or beta-hCG

• Imaging

  • Obtain abdominal ultrasound

  • Equivocal abdominal ultrasound: Consider clinical re-evaluation in 12 hours vs. abdominal CT with IV contrast pending calculated appendicitis risk (see below)

• Calculate risk for appendicitis:

  • Children: Pediatric Appendicitis Score

  • Adults: Appendicitis Inflammatory Response Score

• Appendicitis suspected

  • Consult surgery

  • Morphine 0.1 mg/kg for pain control

  • Monitor for wound infection/post-surgical complications s/p procedure

• Pt counseled that even with appropriate care, perforation occurs in ~20% of patients

Notes

• Special populations

  • Appendicitis is less common in patients younger than 5 and may present differently

  • Appendix location changes during pregnancy and may alter exam findings

• Exam maneuvers

  • Psoas sign: Pain elicited when pt lies on left side and examiner straightens and extends extends the R leg

  • Obturator sign: Pain with passive internal rotation of L thigh

  • Rovsing sign: RLQ pain with palpation of LLQ

• Labs/Imaging

  • A normal WBC does not rule out appendicitis

  • Absolute neutrophil count (ANC) = [WBC * (% segmented neutrophils + % segmented bands)] * 10

  • APPY1 panel

    • Includes WBC, CRP, and myeloid reactive protein

    • Has prognostic value when combined with U/S, but may not be readily available some institutions

  • Choosing wisely: Avoid CT as first line imaging modality in pediatric patients

• Treatment

  • New evidence suggests that uncomplicated cases can be treated with antibiotics; however, 40% of patients still require surgery within 1 year of treatment

  • Morphine does not increase perforation risk, but may only provide pain relief equivalent to placebo

  • Prompt surgical consult reduces perforation risk