From the Guidelines
Acute appendicitis in children typically presents with abdominal pain that initially starts around the umbilicus and then migrates to the right lower quadrant, although this classic pain pattern may be less reliable in younger children who often have difficulty localizing their pain. The clinical presentation of acute appendicitis in pediatric patients can vary depending on the age of the child. Children commonly experience associated symptoms including nausea, vomiting, decreased appetite, and fever 1. Physical examination may reveal tenderness at McBurney's point (located one-third of the distance from the anterior superior iliac spine to the umbilicus), guarding, and rebound tenderness. Children might demonstrate pain with walking, jumping, or coughing. Laboratory findings often show leukocytosis with a left shift, though normal white blood cell counts don't exclude the diagnosis 1.
Some key points to consider in the clinical presentation of acute appendicitis in children include:
- Younger children frequently present with more advanced disease due to communication barriers and atypical presentations 1
- Infants may show only irritability, lethargy, or feeding intolerance
- Adolescents typically present more similarly to adults
- The progression of symptoms is usually rapid, with most children developing significant symptoms within 24-48 hours of onset
- Prompt medical evaluation is essential as delayed diagnosis increases the risk of perforation, which occurs more commonly and rapidly in children than adults due to their thinner appendiceal walls and less developed omentum 1
It's also important to note that clinical scoring systems, such as the Alvarado Score and Pediatric Appendicitis Score, can be used to risk stratify patients and guide imaging and clinical management, but imaging should still be considered in cases where clinical judgement is at odds with the high- or low-risk stratification based on a scoring system 1. The most important consideration in the clinical presentation of acute appendicitis in children is to prioritize prompt medical evaluation and treatment to reduce the risk of perforation and improve outcomes.
From the Research
Clinical Presentations of Acute Appendicitis in Pediatric Patients
The clinical presentations of acute appendicitis in pediatric patients can vary, but common symptoms include:
- Pain, which is the most common presenting symptom in children less than 5 years old 2
- Vomiting, fever, anorexia, and diarrhea 2, 3
- Focal tenderness, guarding, diffuse tenderness, rebound tenderness, and mass 2
- Abdominal distension, which is a common presentation in neonatal appendicitis 2, 4
- Periumbilical pain that migrates to the right iliac fossa, anorexia, fever, and tenderness and guarding in the right iliac fossa 5
Physical Examination Findings
Physical examination findings suggestive of acute appendicitis in children include:
- Decreased or absent bowel sounds 6
- Psoas sign, obturator sign, Rovsing sign, and right lower quadrant rebound tenderness 6
- Guarding and rigidity 6
- Focal tenderness and mass 2
Laboratory and Imaging Evaluation
Initial laboratory evaluation may include:
- Urinalysis 6
- Complete blood cell count 6
- Human chorionic gonadotropin, lactate, and C-reactive protein levels 6
- Comprehensive metabolic profile 6
- Ultrasonography, including point-of-care ultrasonography, is the preferred initial imaging modality due to its low cost, ease of use, and lack of ionizing radiation 6
Predictors of Acute Appendicitis
Independent predictors of acute appendicitis include: