Appendicitis

Paediatric

Emedicine article on paediatric appendicitis

Acute appendicitis is one of the most common causes of abdominal pain and the most frequent condition leading to emergent abdominal surgery in children.

Pathophysiology

• Obstruction of appendix due to lymphoid hyperplasia or a faecolith

• Leads to ischemia due to vascular compression, thus to bacterial overgrowth

• Then to inflammation and possible rupture

• Process = 72 hrs

• Post-rupture peritonitis

History

• Vague periumbilical pain, followed by nausea, vomiting, and anorexia

• Pain moves to lower right quadrant

• Perforation gives transitory relief, followed by more generalised pain

• Nausea and vomiting generally rare, but more common with retrocecal appendices as they irritate the duodenum

• Diarrhoea also uncommon except with a pelvic location which causes irritative stimulation of the rectum (usually not true diarrhoea)

• Severe fever is uncommon and some patients may be afebrile

Physical

• Discomfort

• Withdrawn, unmoving

• Patients are often dehydrated or in pain and may be tachycardic or tachypneic

• Typically, maximal tenderness can be found at the McBurney point in the right lower quadrant. However, the appendix may lie in many positions.

  • • A medially positioned appendix may present as suprapubic tenderness.

    • Patients with a laterally positioned appendix often have flank tenderness.

    • Patients with a retrocecal appendix may not have any tenderness until it is advanced or perforated.

• • Involuntary guarding of the rectus or oblique muscles

  • Rovsing sign / psoas sign / obturator sign

  • Should always perform rectal exam

    • Right-sided tenderness of the rectum is the classic finding in pelvic appendicitis or in pus that pools in the pelvis from an inflamed appendix elsewhere in the abdomen

Differential diagnoses