Acute Appendicitis

Appendicitis is inflammation of the appendix, an anatomically blind

pouch connected to the caecum.

It is a common cause of surgical emergency, and is the most

common cause of an acute abdomen in children

Appendicitis is caused by obstruction of the lumen of the appendix,

usually by a faecolith.

This obstruction allows a build up of intraluminal fluid which

distends the appendix, with a resultant blockage in lymph and
venous drainage.

Ischaemic injury consequentially allows bacterial invasion of the

appendiceal wall and additional inflammatory oedema and
exudation further exacerbates the drainage problems.

This can result in an appendix abscess if pus collects around it, or

perforation of the appendix with possible deadly consequences.

A ruptured appendix will leak feacal matter into the abdomen

causing peritonitis and will lead to septicaemia and death if
untreated.

Appendicitis in a child is the same as appendicitis in an adult but

children are not always able to express themselves as easily.

History
The most common mnemonic used for pain is SOCRATES:

Site
Begin centrally, moving over to the right iliac fossa (RIF) within a
number of hours.
A point of particular tenderness can be localised 1/3's of the way
between the anterior superior iliac spine and the umbilicus, and
is known as McBurney's point.

Onset: 24-48 hour period.

Character: colicky

Radiation: pain to the RIF

It is always important to consider additional symptoms,

particularly anorexia,nausea/vomiting and fever, in suspected
appendicitis. Loss of appetite is a very useful screening question to
ask. Sore tummies in children are very common but the appendicitis
child rarely wants anything to eat.
There is no particular association with timing.

Patients commonly demonstrate a reluctance to move with shallow

breathing as movement can exacerbate the pain. Coughing may also
hurt.

Pain may not be severe to begin with but once localisation occurs
and/or peritonism develops, pain levels will increase and there will be
particular tenderness over the RIF.

As with all children:

Any problems urinating?

In all boys: Is there any testicular pain?

In pubertal girls: Is there any chance they could be pregnant? Are

they sexually active? Last menstrual period?
When was their last stool? Was it hard? Was it loose? Was it sore?

Examination
Some key points to the abdominal examination in a child with suspected
appendicitis:

How does the child walk into the examination room or get onto the
bed? The child who comfortably walks over to you standing tall and
upright is very unlikely to have appendicitis. The child who walks
hunched over, like 'an old man', you must be thinking of peritonitis.
Obviously appendicitis is much more likely in this case.

Do they look unwell? Kids with appendicitis generally aren't nagging

mum for food, running about or climbing on chairs.

Where is the pain exactly? Is it in the right iliac fossa? Is there

true guarding?

If they have pain in a number of areas, e.g. both LIF and RIF,
designate each a number and ask 'Which is more painful, 1 or 2?'

Always, always, always examine the testicles in a boy with a

sore abdomen. These kids will always be embarrassed and may
be pretending the pain is a little higher. A testicular torsion is
something not to be missed.

Special tests
Three such tests are Rovsing's sign, obturator test and the psoas sign. It is
important to know at least Rovsing's sign.

Rovsing's sign is positive if palpation of the left iliac fossa induces

pain in the RIF. It is a demonstration of peritonism and is often a useful
discriminator clinically.

The obturator test, or 'Cope's test', involves flexion and internal

rotation of the right hip. A positive result is if this manoeuvre causes
pain in the RIF, said to be the result if obturator internus muscle is in
close relation to an inflamed pelvic appendix.

The psoas sign is performed by asking the patient to lie on their left
hand side and then extending the right hip. An inflamed retrocaecal or
pelvic appendix close to the right psoas muscle is irritated by this
movement. This causes pain in the RIF.

It is also important to look out for signs of peritonitis which include

abdominal tenderness, guarding and rigidity and a reluctance to move.
Peritonitis is a result of perforation of the appendix and is associated with
a higher degree of mortality and complications.

Investigations
- A full blood count should be ordered to look for a raised white blood
cell (WBC) count. Group & save should be taken for any possible surgical
presentation.
- Urine dipstix and microscopy and culture should be performed to exclude
infection.
- An abdominal ultrasound can be used if the diagnosis is in doubt and can
be used to rule out ovarian pathology.
- Appendicitis itself is not apparent on an abdominal plain flim but X-ray
may help to make diagnoses such as intestinal obstruction, constipation
and intussusception less likely.
Appendicitis is largely a clinical diagnosis, but the Alvarado appendicitis
score is occasionally used as a useful scoring system for assessing the
likelihood of appendicitis. It can be tallied up after a full history,
examination and some initial blood tests have been taken.

Alvarado score

A score lower than 5 suggests appendicitis is less likely, with a score

greater than 8 suggesting a high probability of appendicitis.
Management
Surgery is the mainstay of treatment for appendicitis although pain
management is also key.
Prior to surgery patients need to be kept nil by mouth and will be given
intravenous fluids, antibiotics and analgesia. Metronidazole 500mg/8h and
cefuroxime 1.5g/8h, 1 to 3 doses IV starting 1 hour pro-op, reduces wound
infections. A longer course would be indicated in perforation.
Appendicectomy can then be performed either by open surgery or
laparoscopically.
Open surgery uses the traditional Gridiron incision over McBurneys point,
at a 900 angle to the line from the umbilicus to the anterior superior iliac
spine. Laparoscopic surgery involves 3 small incisions and has many
advantages over open surgery including decreased postoperative pain,
better aesthetic result, and a lower incidence of wound infection and
dehiscence.
Sometimes patients are managed with fluids and antibiotics with
frequently re-assessed and then an elective appendicectomy is arranged
for a number of weeks later.
If an abscess has formed, a drain will need to be inserted to first drain the
pus and the appendix is later removed.
Hints and Tips
In a surgeon's eyes there is no such thing as a grumbling appendix!
Rebound tenderness isn't nice and it's not a good idea to perform it on a
child as they will associated you with the extreme pain and may not allow
you to examine them further! Instead you can ask them to cough or, as I
was advised, get them to jump up and down. The inflamed appendix will
rub on the surrounding tissues and peritoneum and can replicate the pain.
In pregnancy, pain and tenderness are higher because of the
displacement of the appendix by the enlarging uterus. NB: A pregnancy
test should always be performed on females to rule out ectopic pregnancy.

Attempt to involve a child in a history in order to gain their trust and

speak at a level appropriate to their age.
Sometimes it is necessary to perform an examination out of order so that
important aspects are covered before a child becomes uncooperative, e.g.
listening to a child's chest or abdomen while they are quiet.
Growth charts are very important, always think about them and/or ask to
see it.