Volume 19, Number 10 / October 2014

www.ahcmedia.com

Authors: Pediatric Appendicitis

M. Fernanda Bellolio, MD, MS,
Assistant Professor of Emergency The diagnosis of acute appendicitis remains a challenging conundrum for
Medicine, Associate Research the emergency physician. The differential is exceptionally broad and the presen-
Chair, Department of Emergency tation can vary from vague nausea to classical McBurney’s point tenderness.
Medicine, Mayo Clinic, Rochester, Incorporating various imaging modalities in the diagnosis of appendicitis has
MN drastically reduced the rate of negative appendectomies. However, determining
Amy O’Neil, MD, MPH, Senior which patients warrant more extensive imaging requires an astute physician who
Resident, Emergency Medicine, maintains a high index of suspicion for the diagnosis. This review will discuss
Mayo Clinic, Rochester, MN the presentation of appendicitis, analyze the various scoring systems that may be
used by the emergency provider, examine laboratory and radiologic adjuncts, and
review current management strategies.
Peer Reviewer: — Ann M. Dietrich, MD, FAAP, FACEP, Editor
Samuel H.F. Lam, MD, RDMS,
FACEP, Attending Physician, “Almost every surgeon has at one time gone in for an acute appendix when the
Advocate Christ Medical Center, real cause of the symptoms was influenza, beginning pneumonia, diaphragmatic
Oak Lawn, IL; Clinical Associate pleurisy, acute gastritis, ureteral calculus, fecal impaction, dysmenorrhea, onset
Professor of Emergency Medicine, of menstruation in a girl about puberty, tubercular peritonitis, floating kidney,
University of Illinois at Chicago perinephritic abscess, salpingitis, or any number of other rarer conditions.”
~ George Blackburne, MD
Journal of the Medical Society of New Jersey, 1922

Case
A 4-year-old female patient presents to the emergency department (ED) with
her mother complaining of nausea, anorexia, and abdominal pain that began
this morning. She has been febrile to 38° C. She denies having diarrhea. On physi-
cal exam she is laying still and whimpering. She has pain to palpation that is pri-
marily periumbilical without abdominal rigidity.
What evaluation is necessary? Is laboratory testing needed? Are pediatric
appendicitis scores useful in determining the course of evaluation? What imaging
is indicated? Do antibiotics need to be started and if so, which one(s)? Does the
patient need to go to the operating room tonight?
Statement of Financial Disclosure Definition and Etiology
To reveal any potential bias in this publication, and in
accordance with Accreditation Council for Continuing Appendicitis is an inflammatory condition of the appendix that can progress
Medical Education guidelines, we disclose that to rupture with suppurative or gangrenous complications if left untreated.1
Dr. Dietrich (editor), Dr. Skrainka (CME question
reviewer), Dr. Bellolio (author), Dr. O’Neil (author), Though it is frequently encountered by the emergency physician and is the
Dr. Lam (peer reviewer), Ms. Coplin (executive editor), most common surgical emergency in children, the etiology remains unclear.2
and Ms. Kimball (managing editor) report no relation-
ships with companies related to the field of study cov- The classic teaching is that obstruction occurs within the lumen of the appen-
ered by this CME activity. dix, resulting in a progressive increase in intraluminal pressure and subsequent
venous congestion that leads to progressive inflammatory changes and isch-
emia.3,4 Obstruction occurs in 50-80% of appendicitis and in children is most
often due to fecaliths or lymphoid hyperplasia.1 The most common causes of
lymphoid hyperplasia are due to catarrhal inflammation secondary to viral or
AHC Media
 Executive Summary
zz The risk of perforation is significantly increased in obese be used to supplement decision-making but cannot be
children, children 0-4 years of age, and patients present- solely relied upon for the diagnosis of acute appendicitis.
ing with a longer duration of symptoms. zz A meta-analysis by Doria et al found that the pooled
zz Young children under the age of 2 years can be particu- sensitivity and specificity of computerized tomography
larly challenging and may present with fever, irritability, (CT) are significantly higher than ultrasonography
vomiting, grunting, abdominal pain, diarrhea, right hip (US). The sensitivity of US is directly correlated with
pain, or limp. the experience of the operator.
zz The Alvarado Score is a 10-point scoring system with zz A recommended approach to imaging is to begin with
sensitivity ranging from 76-90% and specificity of an abdominal US in those patients with intermediate
72-79%. The Pediatric Appendicitis Score is also a risk of appendicitis followed by CT or surgical
10-point scoring system with a sensitivity ranging from consultation for equivocal exams or when the
57-96% and specificity between 74-97%. They should appendix is not visualized.

bacterial infections, constipation, ED physicians seeing pediatric predictors of appendicitis with a

trauma, and diet.5 Many cases of patients.15 positive likelihood ratio of 3.8 and
appendicitis have been confirmed 3.0, respectively.4,18 (See Table 1.)
without any evidence of obstruc- Clinical Features Patients presenting with symp-
tion, and the cause of appendiceal The classic presentation of appen- toms for > 24 hours in duration
inflammation in these cases remains dicitis includes fever, abdominal pain are more likely to have appendiceal
unclear. and tenderness, or guarding in the perforation.19 Those patients are
right lower quadrant. (See Figure 1.) also more likely to have guarding on
Epidemiology Approximately one-third of patients physical exam, while patients with
Acute appendicitis has an annual present with atypical symptoms.16 non-perforated appendix are more
incidence of 37.2 per 10,000 Young children under the age of 2 likely to have McBurney’s point ten-
American children between the ages years can be particularly challenging derness.20 The presence and degree
of 0-14 years.6 The highest fre- and may present with fever, irritabil- of fever has not been shown to be
quency is in patients between 10-14 ity, vomiting, grunting, abdominal reliably associated with an increased
years of age.7,8 The lifetime risk of pain, diarrhea, right hip pain, or risk of perforated appendix.20,21
acute appendicitis is 8.6% in boys limp.4 Their variable presentation
and 6.7% in girls.2 The incidence of is often the cause for delayed diag- Differential Diagnosis
appendicitis tends to be higher in nosis and increased risk of perfora- The differential diagnosis for
white and Hispanic patients than tion. One review found that 4.8% patients presenting with suspected
in African-American and Asian of patients with appendicitis were appendicitis is broad and contributes
patients.8 The risk of perforation missed on initial presentation and to the challenge of appropriately
is significantly increased in obese most often misdiagnosed with acute identifying children with appendici-
children, children 0-4 years of age, gastroenteritis, constipation, and tis. (See Table 2.)
and patients presenting with a lon- emesis.17
ger duration of symptoms.8,9,10,11 The presence of right lower quad- Laboratory Studies
An increased risk of perforation for rant pain is the most useful clinical The laboratory evaluation for
patients living in rural locations and finding in acute appendicitis and acute appendicitis hinges on the
having lower median household has a positive likelihood ratio (LR+) presence of leukocytosis, often
incomes has been suggested.9 of 7.89 (95% confidence interval with neutrophil predominance and
The mortality of appendicitis in [CI], 7.31-8.46).18 The presence of inflammatory marker elevation, par-
children is very low (< 0.3%); how- fever also increases the likelihood ticularly c-reactive protein (CRP)
ever, it is associated with significant of appendicitis (LR+ 3.4; 95% CI, and procalcitonin (PCT). Additional
morbidity including peritonitis, 2.4-4.8); however, it is not very spe- markers that are more specific to
sepsis, and paralytic ileus, particu- cific.4 Periumbilical pain migrating appendicitis, including 5-hydroxy-
larly when complicated by perfora- to the right lower quadrant is less indoleacetic acid (HIAA) in urine,
tion.12,13,14 A 2005 review by Selbst helpful (LR+ 2.06; 95% CI, 1.63- have recently been evaluated, but
et al found that missed appendicitis 2.60). The presence of abdominal at this point still require addi-
is the second most common reason rigidity and rebound tenderness tional research and are not widely
for malpractice claims filed against on exam are moderately strong available.22,23

114 Pediatric Emergency Medicine Reports / October 2014 www.ahcmedia.com

 The presence of leukocytosis sig- Figure 1. Location of the Appendix in the Right Lower
nificantly increases the probability Quadrant of the Abdomen
of appendicitis with a predictive
value that is directly correlated with
degree of leukocytosis. The posi-
tive likelihood ratio for white blood
cell count (WBC) > 10,000/mm3
is 2.47 (95% CI, 2.06-2.95), and
increases to 3.47 (95% CI, 1.6-7.8)
for WBC > 15,000/mm3.18 The
WBC rises earliest in the disease
process and appears to be the most
useful marker when symptoms are
present for < 24 hours.24
An elevation in CRP > 3 mg/dL
has a sensitivity and specificity for
appendicitis of 95% and 74%, respec-
tively.25 CRP tends to rise slightly
later in the disease process and is
most useful between 24-48 hours
after symptom onset.24
The meta-analysis by Andersson
et al found a combination of a leu-
kocytosis and elevation of CRP is
strongly predictive of appendicitis;
the positive likelihood ratio is 23.32
(95% CI, 6.87-84.79) and negative
likelihood ratio is 0.03 (95% CI,
0.0-0.14).26 Although this combi-
nation is strongly correlated with
appendicitis, patients, particularly
those early in the disease process,
can still present with both a normal
WBC count and CRP and therefore
cannot be excluded based on these
laboratory studies alone.
Studies have evaluated PCT levels Reproduced with authorization from Mayo Clinic.
in appendicitis and found a sensitiv-
ity and specificity of 33% (95% CI,
21-47) and 89% (95% CI, 78-95), Table 1. Signs and Symptoms Associated with Acute
respectively.27 PCT in the setting of Appendicitis
complicated appendicitis is signifi-
cantly more predictive, with sensitiv- Positive Likelihood Negative Likelihood
ity and specificity of 62% (95% CI, Sign/Symptom Ratio Ratio
33-84) and 94% (95% CI, 90-96).27 Right lower quadrant
Its application is most useful in pre- 7.89 0.14
pain
dicting the presence of complicated
appendicitis. Fever 3.4 0.32
Urinalysis can be helpful to pre-
dict simple vs perforated appendici- Periumbilical pain
2.06 0.42
tis. The presence of more than 2.0 migration
red blood cells (RBC)/high power
field has a positive likelihood ratio Percussion tenderness 4.07 0.50
of 4.76, and presence of more than Rebound tenderness 3.0 0.28
4.0 WBC/high power field has a
positive likelihood ratio of 2.33 for Adapted from: Acheson J, Banerjee J. Management of suspected appendicitis in
appendicitis.28 children. Arch Dis Child Educ Pract Ed 2010;95:9-13.

www.ahcmedia.com Pediatric Emergency Medicine Reports / October 2014 115

 Table 2. Differential Diagnosis for Right Lower Quadrant
Table 3. Alvarado Score
Pain
Systems Diagnoses Feature Score
Acute gastroenteritis Migration of pain 1
Appendicitis
Anorexia 1
Constipation
Intussusception Nausea and vomiting 1
Gastrointestinal
Intestinal malrotation
Tenderness in the right
Meckel’s diverticulum 2
lower quadrant
Mesenteric lymphadenitis
Henoch Schonlein purpura Rebound tenderness 1

Urinary tract infection Temperature > 37.5° C 1

Pyelonephritis
Leukocytosis > 10,000/
Genitourinary Nephrolithiasis 2
mm3
Testicular torsion
Left shift 1
Epididymitis
Total 10
Ovarian torsion
Ovarian cyst
Gynecologic Ectopic pregnancy Table 4. Pediatric
Mittelschmerz Appendicitis Score
Pelvic inflammatory disease Feature Score
Fever > 38° C 1
Lobar pneumonia
Diabetic ketoacidosis Anorexia 1
Extra Abdominal
Hemolytic uremic syndrome
Nausea or vomiting 1
Henoch Schonlein purpura
Cough, percussion, or
2
Clinical Prediction Rules hopping tenderness
likelihood of appendicitis and rec-
Given the complexity of presenta- ommends evaluation with imaging. Right lower quadrant
tions and non-specific laboratory A score of ≤ 3 suggests a very low 2
tenderness
findings, clinical prediction rules likelihood of appendicitis and rec-
have been developed to guide the ommends against further imaging. Migration of pain 1
management of patients with sus- The Pediatric Appendicitis Score is
pected appendicitis. The two most also a 10-point scoring system with
Leukocytosis > 10,000/
commonly used prediction rules are a sensitivity ranging from 57-96% 1
mm3
the Alvarado Score and the Pediatric and specificity between 74-97%.4
Appendicitis Score. (See Table 4). A score of ≥ 6 recom-
Polymorophonuclear-
The Alvarado Score is a 10-point mends surgical consultation, 3-5
neutrophilia > 7500/ 1
scoring system with sensitivity rang- recommends further imaging and ≤
mm3
ing from 76-90% and specificity of 2 recommends no further workup
72-79%.4 (See Table 3.) A score of for appendicitis. A score of ≥ 6 has a
≥ 7 has a positive predictive value positive predictive value of 45% for Total 10
of 65% for appendicitis and recom- appendicitis.4
mends surgical consultation.4 A While these scoring systems can
score of 4-6 has an intermediate help to direct the clinician, both lack

116 Pediatric Emergency Medicine Reports / October 2014 www.ahcmedia.com

the sensitivity and positive predic- Figure 2. CT of Dilated Appendix with 1.3 cm
tive value needed to reliably make Appendicolith
a diagnosis. They should be used
to supplement decision-making but
cannot be solely relied upon for the
diagnosis of acute appendicitis.

Radiologic Studies
Much controversy has surrounded
the choice of imaging to best evalu-
ate for appendicitis in children.
The National Ambulatory Medical
Care Survey found that the use of
computerized tomography (CT) to
diagnose appendicitis has increased
from nearly 0% in 1992 to 59.8% in
2006.29 Since that time, a height-
ened awareness of the risks associ-
ated with CT imaging and more
readily available ultrasonography
(US) has led to decreasing use of
CT and increasing use of US.30
CT has the benefits of greater
sensitivity and accuracy for the diag- 
nosis of appendicitis, the ability to
evaluate for other intra-abdominal
pathology causing symptoms, and
lack of operator variability in accu-
racy. This comes at the cost of ioniz-
ing radiation exposure and potential
contrast reactions. The predicted
lifetime risk for radiation-induced
cancer after receiving one abdominal
CT in a 5-year-old child is estimated
to be 26.1 per 100,000 in girls and
20.4 per 100,000 in boys.31 In an
effort to decrease ionizing radia-
tion exposure, many institutions
have initiated low-dose CT imaging Hospitals designated as children’s This is due to the paucity of intra-
with reduction in radiation dose hospitals, teaching centers, or in an abdominal fat in children and allows
by approximately 60% and found urban location were also less likely for improved sensitivity in detec-
similar sensitivities and specificities to perform CT imaging alone for tion of appendicitis compared to
in diagnosis.32 While CT has signifi- appendicitis.34 CT without contrast.36 Contrast
cantly decreased the rate of negative US offers a safe and less expen- given enterally does not significantly
appendectomies, it has not led to a sive alternative diagnostic strategy, improve diagnostic value and is
decrease in perforation rate.2 but at the expense of accuracy and often vomited, leading to patient
The use of CT is slowly starting to operator reliance. Facilities that use discomfort and delays in evalua-
decline, though practice variations US frequently and have technicians tion.37 The CT findings suggestive
in its use are prevalent. A review who are facile in its application have of appendicitis include an appendix
by Ladd et al found that children a much greater sensitivity for detec- > 6 mm in diameter, peri-appendi-
initially presenting to a refer- tion of appendicitis than low-volume ceal inflammation or fat stranding,
ring hospital, female patients, and centers.35 However, the hours of US abscess, or presence of appendico-
patients with a prolonged latency availability are still limited in a num- lith.4 (See Figure 2.)
from symptom onset to presentation ber of facilities, often leaving CT as The diagnosis of appendicitis on
increased the probability of receiving the only option late at night. US is demonstrated by an aperistal-
CT. The presence of rebound ten- CT scan of the abdomen is best tic, blind ending structure arising
derness decreased the probability.33 done with intravenous (IV) contrast. from the cecum that is > 6 mm in

www.ahcmedia.com Pediatric Emergency Medicine Reports / October 2014 117

Figure 3. US of dilated appendix to 8 mm

diameter, tender, and non-com- appendicitis is not similarly affected As magnetic resonance imaging
pressible. Inflammatory changes by symptom duration. Many studies (MRI) is becoming more widely
such as wall thickening, increased have evaluated the effect of obesity available, it may offer an excel-
blood flow, echogenic perice- on visualization of the appendix lent alternative to CT and US for
cal fat stranding, and presence of with US. Conflicting evidence has the diagnosis of appendicitis. MRI
appendicolith or free fluid are also been reported, although there does avoids exposure to radiation while
highly suggestive of the diagnosis.14 seem to be a trend toward a higher maintaining excellent test perfor-
(See Figure 3.) In approximately rate of non-diagnostic ultrasounds mance. The sensitivity and specific-
42-47% of US, the appendix is not in obese patients.10,40,41,42,43 These ity of MRI are 100% and 96-99%,
visualized and further work-up is patients then require CT for further respectively. It has a negative pre-
required.38 evaluation, as there is no decrease dictive value of 100% and positive
A meta-analysis by Doria et al in sensitivity of CT for patients who predictive value of 83-98%. 44,45 The
found that the pooled sensitiv- are obese.40 greatest challenges of MRI at this
ity and specificity of CT are sig-
nificantly higher than US.39 (See Table 5. Pooled Sensitivity and Specificity of CT and US in
Table 5.) The sensitivity of US is Diagnosis of Appendicitis
directly correlated with the experi-
Pooled Sensitivity % Pooled Specificity %
ence of the operator.35 One study
by Bachur et al also found that the (95% CI) (95% CI)
sensitivity of US in detection of CT Scan 94 (92-97) 95 (94-97)
appendicitis is increased in patients
who present with longer durations Ultrasound 88 (86-90) 94 (92-95)
of symptoms.2 CT detection of

118 Pediatric Emergency Medicine Reports / October 2014 www.ahcmedia.com

time are limited availability and cost. advanced generation cephalosporin management.58,59
A recommended approach to such as ceftriaxone and metroni- Cases of perforated appendicitis
imaging is to begin with an abdomi- dazole.52 Cases of uncomplicated that have developed an abscess or
nal US in those patients with inter- appendicitis often do not require appendiceal phlegmon are often
mediate risk of appendicitis followed postoperative antibiotic treat- managed non-operatively with
by CT or surgical consultation for ment. Perforated appendicitis percutaneous drain placement and
equivocal exams or when the appen- requires a prolonged course with IV IV antibiotics followed by inter-
dix is not visualized.46 This approach antibiotics.52 val appendectomy. A prospective
has yielded a sensitivity and speci- The management of appendicitis randomized controlled trial by St.
ficity of 98.6% and 90.6%, respec- is primarily surgical. One study by Peter et al found that there was no
tively.47 Institutional studies that Yardeni et al found that patients significant difference in length of
have moved to a protocolized work- taken to the operating room (OR) hospitalization or recurrent abscess
up using this staged approach have within 6 hours of ED triage did not when patients were managed with
decreased use of CT by at least 50% result in any increase in perforation drain placement and interval appen-
and have not found a statistically rate, length of stay, or complications dectomy compared to patients taken
increased risk of perforation.48,49 compared to patients taken to the directly for appendectomy. There
OR between 6 and 24 hours of ED was a trend toward longer operating
Management triage.53 If the patient is hemody- times for patients taken for immedi-
The ED management of appendi- namically stable without evidence ate appendectomy.60
citis is primarily focused on correc- of septic shock, the patient should
tion of dehydration, pain control, be taken to the OR within 24 hours Disposition
and timely antibiotic administration. of presentation at a time when Patients need to be stabilized in
Patients typically present dehydrated resources and staffing are readily the ED initially along with prompt
due to anorexia and vomiting and available. surgical consultation. The stable
should have an IV established to Most cases of non-perforated patient may be admitted for appen-
begin rehydration. This can be appendicitis are treated operatively dectomy within 24 hours from pre-
accomplished with a 20 mL/kg fluid and primarily by laparoscopic appen- sentation. Those who have evidence
bolus of isotonic crystalloid until dectomy.9 Complications includ- of septic shock require prompt sur-
clinical signs of dehydration have ing wound infection, abscess, and gical intervention and potential ICU
resolved. Patients should then be bowel obstruction within 30 days of admission.
placed on maintenance fluid at 1-1.5 operating are significantly reduced
times the calculated rate. when a laparoscopic approach is Conclusion
Ensuring appropriate pediatric used compared to open appen- Children commonly present
analgesia is frequently overlooked, dectomy.54,55 A growing body of with abdominal pain, which has a
as these patients tend to be under- evidence has found that pediatric broad differential. Diagnosing acute
dosed or do not receive adequate patients with early appendicitis appendicitis requires a high degree
pain control.29 Analgesia is best may be treated with antibiotics of suspicion and a logical approach
achieved using parenteral narcotics. alone without operative interven- to minimize the morbidity associ-
Morphine 0.1 mg/kg IV or fentanyl tion; however, studies with longer ated with this disease. The judicious
1 mcg/kg IV are safe and effective periods of follow-up to determine use of diagnostic studies including
options. risk of recurrence in children are ultrasound and CT may further
Patients with evidence of non-per- still needed.56 The Non-Operative delineate the clinicians diagnostic
forated appendicitis should receive Treatment for Acute Appendicitis concerns for this condition. Timely
prophylactic antibiotics in the (NOTA) study in adults found surgical consultation for further
ED to decrease the risk of wound an 83% efficacy rate at 2 years management is a critical aspect to
infections and intra-abdominal follow-up.57 the acute care of these children.
abscess.50 The bacteria most often Patients with perforated appen-
found in appendicitis is Escherichia dicitis are increasingly being References
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using either a single broad-spectrum and hospital re-admissions.58 The The effect of abdominal pain dura-
agent such a piperacillin-tazobactam presence of appendicolith increases tion on the accuracy of diagnostic
or double-agent therapy with an the failure rate of non-operative imaging for pediatric appendicitis.

www.ahcmedia.com Pediatric Emergency Medicine Reports / October 2014 119

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15. Selbst SM, Friedman MJ, Singh SB. 37. 38. Jaremko JL, Crockett A, Rucker D,
Epidemiology and etiology of mal- 27. Yu CW, Juan LI, Wu MH, et al. Magnus KG. Incidence and signifi-
practice lawsuits involving children Systematic review and meta-analysis cance of inconclusive results in ultra-

120 Pediatric Emergency Medicine Reports / October 2014 www.ahcmedia.com

 sound for appendicitis in children placebo for the prevention of post- 54. Gasior AC, St Peter SD, Knott
and teenagers. Can Assoc Radiol J operative infection after appendicec- EM, et al. National trends in
2011;62:197-202. tomy. Cochrane Database Syst Rev approach and outcomes with appen-
39. Doria AS, Moineddin R, 2005;CD001439. dicitis in children. J Pediatr Surg
Kellenberger CJ, et al. US or CT 51. Chen CY, Chen YC, Pu HN, et al. 2012;47:2264-2267.
for diagnosis of appendicitis in chil- Bacteriology of acute appendicitis 55. Lee SL, Yaghoubian A, Kaji A.
dren and adults? A meta-analysis. and its implication for the use of Laparoscopic vs open appendectomy
Radiology 2006;241:83-94. prophylactic antibiotics. Surg Infect in children: Outcomes comparison
40. Abo A, Shannon M, Taylor G, (Larchmt) 2012;13:383-390. based on age, sex, and perforation
Bachur R. The influence of body 52. Lee SL, Islam S, Cassidy LD, et al. status. Arch Surg 2011;146:1118-
mass index on the accuracy of ultra- Antibiotics and appendicitis in the 1121.
sound and computed tomography in pediatric population: An American 56. Armstrong J, Merritt N, Jones S, et
diagnosing appendicitis in children. Pediatric Surgical Association al. Non-operative management of
Pediatr Emerg Care 2011;27:731- Outcomes and Clinical Trials early, acute appendicitis in children:
736. Committee systematic review. J Is it safe and effective? J Pediatr Surg
41. Butler M, Servaes S, Srinivasan A, Pediatr Surg 2010;45:2181-2185. 2014;49:782-785.
et al. US depiction of the appendix: 53. Yardeni D, Hirschl RB, Drongowski 57. Di Saverio S, Sibilio A, Giorgini E, et
Role of abdominal wall thickness and RA, et al. Delayed versus immediate al. The NOTA Study (Non Operative
appendiceal location. Emerg Radiol surgery in acute appendicitis: Do we Treatment for Acute Appendicitis):
2011;18:525-531. need to operate during the night? J Prospective study on the efficacy and
42. Sulowski C, Doria AS, Langer JC, et Pediatr Surg 2004;39:464-469. safety of antibiotics (amoxicillin and
al. Clinical outcomes in obese and
normal-weight children undergoing
ultrasound for suspected appendicitis. Now You Can Complete Your Test with Each Issue
Acad Emerg Med 2011;18:167-173.
43. Yigiter M, Kantarci M, Yalcin O, Here’s a change we know you’ll like: From now on, there is no more
et al. Does obesity limit the sono- having to wait until the end of a 6-month semester or calendar year to earn
graphic diagnosis of appendicitis your continuing education credits or to get your credit letter.
in children? J Clin Ultrasound Log on to www.cmecity.com to complete a post-test and brief evaluation
2011;39(4):187-190. after each issue. Once the completed evaluation is completed, a credit letter
44. Goldin AB, Khanna P, Thapa M, et
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al. Revised ultrasound criteria for
appendicitis in children improve
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diagnostic accuracy. Pediatr Radiol the United States at (404) 262-5476. You can also email us at:
2011;41:993-999. [email protected].
45. Johnson AK, Filippi CG, Andrews T,
et al. Ultrafast 3-T MRI in the evalu-
ation of children with acute lower
abdominal pain for the detection of
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www.ahcmedia.com Pediatric Emergency Medicine Reports / October 2014 121

 3. Leukocytosis in patients with sus-
CME Instructions pected appendicitis:
To earn credit for this activity, please follow these instructions: a. is always present.
1. Read and study the activity, using the references for further research. b. increases the probability of
2. Scan the QR code to the right or log on to www. appendicitis.
cmecity.com. c. is not part of prediction
3. Pass the online tests with a score of 100%; you will scores.
be allowed to answer the questions as many times as d. is related to diarrhea.
needed to achieve a score of 100%. 4. Which of the following has the
4. After completing the test, your browser will be highest positive likelihood ratio
directed to the activity evaluation form. for the diagnosis of appendicitis?
5. Once the completed evaluation is received, a credit a. Leukocytosis > 10,000/mm3
letter will be e-mailed to you instantly. b. Leukocytosis > 15,000/mm3
c. Leukocytosis and elevation in
CRP
Pediatric Emergency Medicine Reports
d. Urine with > 2 RBC/high
CME Objectives power field
5. Given the complexity of presenta-
Upon completion of this educational activity, participants should be able to: tions and non-specific laboratory
• recognize specific conditions in pediatric patients presenting to the findings, clinical prediction rules
emergency department; have been developed to guide the
• describe the epidemiology, etiology, pathophysiology, historical and management of patients with sus-
examination findings associated with conditions in pediatric patients pected appendicitis. What is true
presenting to the emergency department; regarding predictions rules for
• formulate a differential diagnosis and perform necessary diagnostic tests; appendicitis?
• apply up-to-date therapeutic techniques to address conditions a. The Alvarado Score is a
discussed in the publication; 10-point scoring system. A
• discuss any discharge or follow-up instructions with patients. score of ≥ 7 suggests a high
likelihood of appendicitis and
recommends surgical consulta-
clavulanic acid) for treating patients CME Questions tion.
with right lower quadrant abdominal
b. The Pediatric Appendicitis
pain and long-term follow-up of con- 1. The differential diagnosis for
servatively treated suspected appendi- Score is a 10-point scoring
patients presenting with sus-
citis. Ann Surg 2014;260:109-117. system. A score of ≥ 7 recom-
pected appendicitis is:
58. Aprahamian CJ, Barnhart DC, mends surgical consultation.
a. broad and contributes to the
Bledsoe SE, et al. Failure in the non- c. The Alvarado score has a high
challenge of appropriately
operative management of pediatric enough sensitivity and speci-
ruptured appendicitis: Predictors identifying children with
ficity to be solely relied upon
and consequences. J Pediatr Surg appendicitis.
for the diagnosis.
2007;42:934-938. b. narrow, as there are not many
d. The Pediatric Appendicitis
59. Zhang HL, Bai YZ, Zhou X, Wang causes of abdominal pain in
Score has a high enough
WL. Nonoperative management of children.
appendiceal phlegmon or abscess sensitivity and specificity to
c. narrow and depends on the
with an appendicolith in children. J be solely relied upon for the
age of the patient.
Gastrointest Surg 2013;17:766-770. diagnosis.
d. broad and is not challenging.
60. St. Peter SD, Aguayo P, Fraser JD, et 6. Which of the following is true
al. Initial laparoscopic appendectomy 2. The laboratory evaluation most
regarding computed tomography
versus initial nonoperative manage- predictive for acute appendicitis
ment and interval appendectomy for (CT) to aid in the diagnosis of
is:
perforated appendicitis with abscess: suspected acute appendicitis?
a. leukocytosis with a neutrophil
A prospective, randomized trial. J a. CT scan has moderate sen-
predominance.
Pediatr Surg 2010;45:236-240. sitivity and accuracy for the
b. inflammatory marker eleva-
diagnosis of appendicitis.
tion, particularly C-reactive
b. Rectal contrast with CT is
protein (CRP).
needed to achieve high accu-
c. elevation of procalcitonin.
racy.
d. leukocytosis in combination
c. CT has higher ionizing radia-
with elevation in CRP.
tion exposure and potential
contrast reactions.

122 Pediatric Emergency Medicine Reports / October 2014 www.ahcmedia.com

 d. CT has significantly decreased is only about making the c. Giving antibiotics post-oper-
the rate of negative appendec- diagnosis. atively to decrease the risk of
tomies and led to a decrease b. The emergency department wound infections and intra
in perforation rate. management of appendicitis abdominal abscess
7. Which of the following is true is primarily focused on d. Initiated fluid replacement
regarding ultrasound (US) in diagnosis, appropriate with dextrose containing fluid
the diagnosis of suspected acute consultation, correction of to prevent hypoglycemia
appendicitis? dehydration, pain control 10. Which of the following is true
a. US has a greater sensitivity and timely antibiotic regarding disposition of a patient
than CT in the diagnosis of administration. with acute appendicitis?
appendicitis. c. There is no role for the a. Patients need to be stabilized
b. The accuracy of US for diag- emergency department in the in the ED initially along
nosing acute appendicitis is management of appendicitis, with prompt surgical
approximately equal to the as it is primarily surgical consultation.
accuracy of CT. management. b. The stable patient may be dis-
c. The diagnosis of appendicitis d. Analgesia is not needed in charged to home with outpa-
on US is demonstrated by a these patients as they will be tient surgical follow-up.
dilated appendix > 6 mm going to the operating room c. Those who have evidence of
that is tender and non- under anesthesia. septic shock can be treated
compressible. 9. Which one is appropriate in the with IV antibiotics alone.
d. MRI is a better alternative to management of a child with acute d. Patients with perforated
US in children. appendicitis? appendicitis should always be
8. Which of the following is the a. Ensuring appropriate analgesia taken directly to the OR.
appropriate management of a with parenteral narcotics
child with acute appendicitis? b. Beginning with 1-1.5x main-
a. The emergency department tenance fluids for children
management of appendicitis

Pediatric Trauma Care II 12

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www.ahcmedia.com Pediatric Emergency Medicine Reports / October 2014 123

 Editors Director, Pediatric Emergency Services, Pediatric Emergency Medicine Medicine, Palomar Health System,
EDITOR IN CHIEF Goryeb Children’s Hospital, Advocate Condell Medical Center Escondido, California
Ann Dietrich, MD, FAAP, FACEP Morristown Memorial Hospital Clinical Associate Professor
Professor of Pediatrics, Ohio State Morristown, New Jersey of Emergency Medicine Jonathan I. Singer, MD, FAAP,
University; Attending Physician, Rosalind Franklin University FACEP
Nationwide Children’s Hospital; Christopher J. Haines, DO, FAAP, Libertyville, Illinois Professor of Emergency Medicine and
Associate Pediatric Medical Director, FACEP Pediatrics, Boonshoft School of Medicine
MedFlight Chief Medical Officer Ronald M. Perkin, MD, MA Wright State University,
Children’s Specialized Hospital Professor and Chairman Dayton, Ohio
EDITOR EMERITUS New Brunswick, New Jersey Department of Pediatrics
Larry B. Mellick, MD, MS, FAAP, Associate Professor of Pediatrics and The Brody School of Medicine
Emergency Medicine Brian S. Skrainka, MD, FAAP, FACEP
FACEP at East Carolina University Medical Director
Professor of Emergency Medicine Drexel University College of Medicine Greenville, North Carolina
Attending Physician Pediatric Emergency Department
Professor of Pediatrics St. David’s North Austin Medical
Georgia Health Sciences University St. Christopher’s Hospital for Children
Philadelphia, Pennsylvania Alfred Sacchetti, MD, FACEP Center
Augusta, Georgia Chief of Emergency Services Austin, Texas
Dennis A. Hernandez, MD Our Lady of Lourdes Medical Center
Editorial Board Medical Director Camden, New Jersey Milton Tenenbein, MD, FRCPC,
Pediatric Emergency Services Clinical Assistant Professor  FAAP, FAACT
James E. Colletti, MD, FAAP,
Walt Disney Pavilion Emergency Medicine Professor of Pediatrics and
FAAEM, FACEP
Florida Hospital for Children Thomas Jefferson University Pharmacology
Associate Residency Director
Orlando, Florida Philadelphia, Pennsylvania University of Manitoba
Emergency Medicine
Mayo Clinic College of Medicine Director of Emergency Services
Rochester, Minnesota John P. Santamaria, MD, FAAP, Children’s Hospital
Steven Krug, MD
FACEP Winnipeg, Manitoba
Head, Division of Pediatric Emergency
Affiliate Professor of Pediatrics
Robert A. Felter, MD, FAAP, CPE, Medicine, Children’s Memorial Hospital
University of South Florida School
FACEP Professor, Department of Pediatrics- James A. Wilde, MD, FAAP
of Medicine, Tampa, Florida
Attending Physician Northwestern University Feinberg Professor of Emergency Medicine,
Emergency Medicine and Trauma School of Medicine Associate Professor of Pediatrics
Center Chicago, Illinois Robert W. Schafermeyer, MD, Georgia Health Sciences University,
Professor of Clinical Pediatrics FACEP, FAAP, FIFEM Augusta, Georgia
Georgetown University School Associate Chair, Department of
Jeffrey Linzer Sr., MD, FAAP, FACEP
of Medicine Emergency Medicine
Assistant Professor of Pediatrics and
Washington, DC Carolinas Medical Center Steven M. Winograd, MD, FACEP
­Emergency Medicine
Charlotte, North Carolina St. Barnabas Hospital, Core Faculty
Emory University School of Medicine
Clinical Professor of Pediatrics Emergency Medicine Residency
George L. Foltin, MD, FAAP, FACEP Associate Medical Director for
and Emergency Medicine Albert Einstein Medical School
Associate Professor of Pediatric Compliance
University of North Carolina School of Bronx, New York
and Emergency Medicine Emergency Pediatric Group
Medicine, Chapel Hill, North Carolina
New York University School of Medicine Children’s Healthcare of Atlanta at © 2014 AHC Media LLC. All rights
New York, New York Egleston and Hughes Spalding reserved.
Atlanta, Georgia Ghazala Q. Sharieff, MD, MBA
Clinical Professor
Michael Gerardi, MD, FAAP, FACEP
Charles Nozicka DO, FAAP, FAAEM University of California, San Diego
Clinical Assistant Professor of Medicine,
Medical Director Director of Pediatric Emergency
New Jersey Medical School

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Exclusive to our subscribers Rapid Access Management Guidelines

Pediatric
Appendicitis

Location of the Appendix in the Right Lower Quadrant of the

Abdomen

Reproduced with authorization from Mayo Clinic.

Signs and Symptoms Associated with Acute Appendicitis

Positive Likelihood Negative Likelihood

Sign/Symptom Ratio Ratio
Right lower quadrant pain 7.89 0.14
Fever 3.4 0.32
Periumbilical pain migration 2.06 0.42
Percussion tenderness 4.07 0.50
Rebound tenderness 3.0 0.28
Adapted from: Acheson J, Banerjee J. Management of suspected appendicitis in children. Arch Dis
Child Educ Pract Ed 2010;95:9-13.

Alvarado Score Pediatric Appendicitis Score

Feature Score Feature Score
Migration of pain 1 Fever > 38° C 1
Anorexia 1 Anorexia 1
Nausea and vomiting 1 Nausea or vomiting 1
Tenderness in the right lower Cough, percussion, or
2 2
quadrant hopping tenderness
Rebound tenderness 1 Right lower quadrant
2
Temperature > 37.5° C 1 tenderness
Leukocytosis > 10,000/mm3 2 Migration of pain 1
Left shift 1 Leukocytosis > 10,000/mm 3
1
Total 10 Polymorophonuclear-
1
neutrophilia > 7500/mm3
Total 10
 Differential Diagnosis for Right Lower Quadrant Pain

Systems Diagnoses
Acute gastroenteritis
Appendicitis
Constipation
Intussusception
Gastrointestinal
Intestinal malrotation
Meckel’s diverticulum
Mesenteric lymphadenitis
Henoch Schonlein purpura
Urinary tract infection
Pyelonephritis
Genitourinary Nephrolithiasis
Testicular torsion
Epididymitis
Ovarian torsion
Ovarian cyst
Gynecologic Ectopic pregnancy
Mittelschmerz
Pelvic inflammatory disease
Lobar pneumonia
Diabetic ketoacidosis
Extra Abdominal
Hemolytic uremic syndrome
Henoch Schonlein purpura

Pooled Sensitivity and Specificity of CT and US in Diagnosis

of Appendicitis
Pooled Sensitivity % Pooled Specificity %
(95% CI) (95% CI)
CT Scan 94 (92-97) 95 (94-97)
Ultrasound 88 (86-90) 94 (92-95)

CT of Dilated Appendix with 1.3 cm Appendicolith

Supplement to Pediatric Emergency Medicine Reports, October 2014: “Pediatric Appendicitis.”

Authors: M. Fernanda Bellolio, MD, MS, Assistant Professor of Emergency Medicine, Associate
Research Chair, Department of Emergency Medicine, Mayo Clinic, Rochester, MN; and Amy O’Neil,
MD, MPH, Senior Resident, Emergency Medicine, Mayo Clinic, Rochester, MN.
Pediatric Emergency Medicine Reports’ “Rapid Access Guidelines.” Copyright © 2014 AHC Media
LLC, Atlanta, GA. Editorial Director: Lee Landenberger. Editor-in-Chief: Ann Dietrich, MD,
FAAP, FACEP. Executive Editor: Leslie Coplin. Managing Editor: Neill Kimball. For customer ser-
vice, call: 1-800-688-2421. This is an educational publication designed to present scientific informa-
tion and opinion to health care professionals. It does not provide advice regarding medical diagnosis or
treatment for any individual case. Not intended for use by the layman.