Appendicitis

If the appendix is in the retrocecum, the pain may be absent in the abdominal area due to overlap by a distended
cecum covering the appendix. Similarly, if the appendix lies in the pelvis, no abdominal pain will be felt in the abdo-
men; rather, pain will be felt on digital rectal examination. Although physical examinations in younger children can
be challenging at best, the physical examination (including repeat examinations, close follow-up, and observation)
and history are key to making the diagnosis.

A high index of suspicion is needed, as delayed presentation and diagnosis often results in perforation. The risk of
perforation in children younger than 4 years of age has been reported to be more than 70%. 6,17

A technique for evaluating rebound tenderness is asking the child to jump up and down. Also, asking the child if he
or she is hungry and would he or she eat their favorite food, if offered (“hamburger sign”), can provide a better
understanding of whether there is anorexia.

Rebound, guarding, and diffuse tenderness are associated with more peritoneal irritation and are concerning for
ruptured appendicitis.

Adolescents
Appendicitis is most likely to occur in this age group,

Male patients should also undergo a complete physical examination, including genitourinary examination.
Ntxt 19

• Acute appendicitis: 60 - 65%

• Perforated appendicitis: 25 - 30%
• Perforated appendicitis with well-defined abscess (5-7 day history): 5 - 10%

Perforation is most common in young children, with rates as high as 82% for children <5 yr and
approaching 100% in infants

Perforation occurs in 15–30% of patients

Greatest in children <5 yr (patients’ inability to communicate their symptoms).
Although the time of perforation is variable, it usually occurs within 36–48 hr of onset of symptoms.
In younger children, in whom perforation can occur within 8 to 24 hours of the onset of symptoms.

More toxic appearance , generalized, rather than localized, peritonitis.

Other signs include significant tachycardia, higher fever , rapid shallow respirations, painful respirations
associated with grunting, and decreased air entry to the lower lung fields.(!! pneumonia)

The WBC count is

significantly elevated, usually higher than 15,000 per mm3, with a marked shift to left