Fascinating Facts about Appendicitis in School-Age Children
What kind of pain is it? 1. Steady or constant 2. Colicky 3. Increases with movement 4. Child has had similar episode before What about other symptoms? 1. Vomiting 2. Diarrhea 3. Constipation 4. Dysuria How about fever and physical findings? 1. Temp > 38º : if pain < 24 hrs, 4% have appendicitis if pain 24-48 hrs, 64% have appendicitis 2. Bowel sounds: normal or hyperactive hypoactive 3. Four most consistent features of appendicitis: vomiting, RLQ pain, abdominal tenderness, guarding If 2 of 4 features present: If 0 or 1 features present: 23% have appendicitis 99.7% do not have appendicitis 93% 7% 68-85% 9-16% 5-28% 4-20% 52-57% 11-35% 40-75% 10-36%
(fever, duration of pain, diarrhea, urinary Sx, anorexia, and rectal tenderness were inconsistently present in children with appendicitis as opposed to those without) How about lab tests? 1. WBC is > 10,000 in: 62% of normal pts 89% of pts with appendicitis 93% of pts with perforated appendicitis 2. UA shows >5 WBC or RBC in 7-25% of children with appendicitis 3. CRP is 43-92% sensitive and 33-95% specific for appendicitis in children with acute abdominal pain
Should I get an X-ray, ultrasound, or CT? 1. Plain films tend to be insensitive and nonspecific, but can identify: free air, appendicolith, RLQ ileus, RLL pneumonia, blurred psoas shadow 2. Pelvic ultrasound is 80-92% sensitive and 86-98% specific for appendicitis 3. US is highly technician-dependent 4. Non-visualization of appendix occurs in 33-51% of normal children, but also in 10% of children with appendicitis 5. US findings identify an alternate Dx in 24- 41% of children without appendicitis 6. CT (abdominal, pelvic) tends to be highly accurate; use of colon contrast can enhance accuracy 7. One study used a strategy of referring equivocal cases for US, then CT if US was non-diagnostic -- strategy proved efficient and saved costs What initial misdiagnoses tend to be made in children with appendicitis? Initial Misdiagnosis Gastroenteritis URI (pharyngitis, sinusitis, OM) Pneumonia Sepsis Urinary tract infection Encephalitis/encephalopathy Febrile seizure Blunt abdominal trauma Unknown % of Cases 42 18 4 4 4 2 2 2 22
Of 181 cases of appendicitis in this study, 50 were initially misdiagnosed. On initial presentation, misdiagnosed patients were younger and more likely to have vomiting before pain onset, constipation, diarrhea, dysuria, and signs and symptoms of upper respiratory infections. Misdiagnosed cases were less likely to have right lower quadrant tenderness and documentation of bowel sounds, peritoneal signs, and rectal examinations. On final presentation, misdiagnosed patients were more likely to have pain duration of more than two days, temperature of more than 38.3 C, and to appear lethargic and irritable