From the Guidelines
Appendicitis in children is a medical emergency that requires prompt surgical intervention, and parents should seek immediate medical attention if their child experiences severe abdominal pain, especially when accompanied by fever, vomiting, or decreased appetite. The diagnosis of appendicitis in children can be challenging due to the variability of presenting symptoms, which may not always follow the classic pattern of periumbilical pain migrating to the right lower quadrant 1. According to the American College of Radiology, acute appendicitis is the most common abdominal surgical urgency/emergency in children, with approximately 70,000 cases per year in the United States 1.
Key Symptoms and Signs
- Severe abdominal pain, which may start around the belly button and migrate to the right lower abdomen
- Fever
- Vomiting
- Decreased appetite
- Inability to walk normally
- Guarding or tenderness in the right lower quadrant
Diagnostic Approach
- Physical examination
- Blood tests for infection markers
- Imaging studies, such as ultrasound or CT scan, which can facilitate management and decrease the rate of negative appendectomies in children with suspected acute appendicitis 1
Management
- Prompt surgical intervention (appendectomy) is usually necessary to prevent rupture and peritonitis
- Nonoperative treatment of early, uncomplicated appendicitis may be considered in some cases, but imaging plays a crucial role in identifying candidates for nonoperative management 1
- While waiting for medical care, it is essential not to give the child food, drinks, laxatives, or pain medications, as these can mask symptoms or complicate diagnosis, and never apply heat to the abdomen as this could increase inflammation.
From the Research
Appendicitis Pain in Pediatric Patients
- Appendicitis is one of the most common surgical pathologies in children, often presenting with right lower quadrant pain 2.
- The diagnosis of appendicitis in children can be challenging, and the goal is to review the predictive utility of presenting signs and symptoms, laboratory tests, and imaging studies in the diagnostic work-up of appendicitis 3.
- Scoring systems, in combination with selective imaging and surgical examination, will diagnose most children with appendicitis 2.
Clinical Presentation and Diagnosis
- Delayed or missed diagnosis in young children is common and is associated with increased rates of perforation 4.
- Several scoring systems have been developed, but there is still no consensus on clinical, laboratory, and imaging criteria for diagnosing appendicitis 4.
- Key age-based historical and physical examination findings, as well as clinical scoring systems, can help guide the workup of appendicitis in children 4.
Management and Treatment
- Nonoperative management has a role in the treatment of both uncomplicated and complicated appendicitis 2.
- Most surgical interventions for appendicitis are now almost exclusively laparoscopic, with trials demonstrating better outcomes for children who undergo index hospitalization appendectomies when perforated 2.
- The management of complicated appendicitis is inconclusive, and guidelines have not been established for the use of personalized antibiotic treatment 5.
- Specific risk factors, such as generalized peritonitis and C-reactive protein (CRP) levels above 20 mg/L at admission, can help identify patients who may require a change in antibiotic regimen 5.