What is the management approach for a child with a physical exam concerning for appendicitis?

From the Guidelines

The management of a child with a physical exam concerning for appendicitis should begin with prompt surgical consultation for possible appendectomy, which remains the definitive treatment, and initial imaging with ultrasound as the first-line study, as recommended by the most recent guidelines 1. Initial steps include keeping the child NPO (nothing by mouth), establishing intravenous access for fluid resuscitation with isotonic fluids (typically normal saline at 10-20 mL/kg), and administering appropriate analgesia such as morphine (0.1 mg/kg IV) or hydromorphone (0.015 mg/kg IV) as needed for pain control. Some key points to consider in the management of suspected appendicitis in children include:

• Antibiotics should be started early, typically with a broad-spectrum regimen such as piperacillin-tazobactam (100 mg/kg/dose of piperacillin component every 8 hours) or a combination of ceftriaxone (50 mg/kg/day) plus metronidazole (30 mg/kg/day divided every 8 hours) to cover enteric gram-negative rods and anaerobes, as suggested by previous guidelines 1.
• Laboratory evaluation should include complete blood count, C-reactive protein, and urinalysis.
• Imaging with ultrasound is typically the first-line study, with CT scan reserved for cases where ultrasound is inconclusive, as recommended by the American College of Radiology 1.
• The use of ultrasound in children is accurate and safe in terms of perforation rates, emergency department re-visits, and negative appendectomy rates, as stated in the 2020 update of the WSES Jerusalem guidelines 1. This approach is essential because appendicitis can rapidly progress to perforation within 24-36 hours of symptom onset, leading to peritonitis, abscess formation, and increased morbidity, particularly in younger children who often present with atypical symptoms and delayed diagnosis. Some of the benefits of using ultrasound as the first-line imaging modality include:
• Reduced exposure to ionizing radiation, which is a major concern in pediatric patients 1.
• Faster and more convenient imaging, which can help reduce the time to diagnosis and treatment.
• Lower cost compared to CT scans, which can help reduce the overall cost of care.

From the Research

Management Approach for a Child with a Physical Exam Concerning for Appendicitis

The management approach for a child with a physical exam concerning for appendicitis involves a combination of history, physical examination, laboratory tests, and imaging studies.

• The physical examination is crucial in diagnosing appendicitis, with right lower quadrant tenderness to palpation being the most important finding 2.
• Laboratory tests such as a complete blood count and urinalysis can be helpful in determining the diagnosis and supporting the presence or absence of appendicitis 2.
• Imaging studies such as ultrasonography and computed tomography (CT) scans can be helpful in equivocal cases, with ultrasonography having an average sensitivity of 87.1% and an average specificity of 89.2% 3.
• The Alvarado score, Pediatric Appendicitis Score, and Appendicitis Inflammatory Response score can be used to stratify patients as low, moderate, or high risk and can help in making a timely diagnosis 4.
• Point-of-care ultrasound (POCUS) has been shown to be diagnostic for acute appendicitis, with a positive POCUS able to rule in the diagnosis without the need for CT or MRI, while a negative POCUS cannot rule out the diagnosis 5.

Diagnostic Findings

The following diagnostic findings can be used to diagnose appendicitis in children:

• History of pain migration to the right lower quadrant (LRQ) (LR+ = 4.81,95% CI = 3.59-6.44) 5
• Presence of cough/hop pain in the physical examination (LR+ = 7.64,95% CI = 5.94-9.83) 5
• Rovsing's sign (LR+ = 3.52,95% CI = 2.65-4.68) 5
• Pediatric Appendicitis Score (PAS) ≥ 9 (LR+ = 5.26,95% CI = 3.34-8.29) 5

Treatment Approach

The treatment approach for a child with appendicitis typically involves surgical consultation and appendectomy via open laparotomy or laparoscopy 4.

• Antibiotics may be considered first-line therapy in selected patients, with ceftriaxone plus metronidazole being a commonly used regimen 6.
• Pain control with opioids, nonsteroidal anti-inflammatory drugs, and acetaminophen should be a priority and does not result in delayed or unnecessary intervention 4.