From the Guidelines
The workup for an 8-year-old male presenting to the Emergency Department (ED) with right lower quadrant (RLQ) pain and rebound tenderness should start with a clinical assessment using a scoring system such as the Alvarado Score or Pediatric Appendicitis Score (PAS) to risk stratify the patient 1.
Clinical Assessment
- The clinical assessment should include a thorough history, physical examination, and laboratory findings to determine the risk of appendicitis.
- The Alvarado Score and PAS are two commonly used scoring systems to evaluate the likelihood of appendicitis in children 1.
- These scoring systems can help identify low-risk patients who may not require imaging and high-risk patients who may require surgical management.
Imaging
- Ultrasound (US) is the recommended initial imaging study for the diagnosis of acute appendicitis in pediatric patients, due to its high diagnostic accuracy and lack of radiation exposure 1.
- US has a sensitivity of 86% and specificity of 94% for the diagnosis of acute appendicitis in children 1.
- If the US is equivocal or nondiagnostic, further imaging with CT or MRI may be considered, depending on the clinical picture and local availability of resources 1.
Laboratory Tests
- Laboratory tests such as complete blood count (CBC) and C-reactive protein (CRP) may be useful in supporting the diagnosis of appendicitis, but should not be relied upon solely for diagnosis 1.
Management
- The management of acute appendicitis in children typically involves surgical intervention, although nonoperative management may be considered in select cases 1.
- The choice of imaging modality and management strategy should be individualized based on the patient's clinical presentation, risk factors, and local resources.
From the Research
Clinical Presentation
- The patient is an 8-year-old male presenting to the Emergency Department (ED) with right lower quadrant (RLQ) pain and rebound tenderness 2, 3, 4.
- The clinical presentation of RLQ pain, fever, nausea/vomiting, diarrhea, or rebound tenderness can be indicative of appendicitis, but other causes of RLQ pain should also be considered 2, 3, 4.
Diagnostic Approach
- A thorough medical history and physical examination are essential in diagnosing the cause of RLQ pain 3.
- Laboratory tests, such as white cell counts, neutrophil percentages, and C-reactive protein levels, can help differentiate between appendicitis and other causes of RLQ pain 2.
- Imaging studies, including abdominal sonography and/or computed tomography, may be necessary to confirm the diagnosis 2, 5, 4.
- The use of advanced nursing directives (ANDs) can help identify children who require further investigation to diagnose appendicitis and improve ED flow metrics 6.
Differential Diagnosis
- Appendicitis is a common cause of RLQ pain in children, but other causes, such as intussusception, ovarian cyst, diverticulitis, and right paraduodenal hernia, should also be considered 2, 5, 4.
- A structured and complete medical history and physical examination, focusing on pain-related symptoms and history of pain, can help diagnose appendicitis and other causes of RLQ pain 3.
- The combination of clinical signs and symptoms, laboratory tests, and imaging studies can be used to differentiate between the causes of RLQ pain 2, 3.