Volume 19, Number 10 / October 2014
www.ahcmedia.com
Authors:
M. Fernanda Bellolio, MD, MS,
Assistant Professor of Emergency
Medicine, Associate Research
Chair, Department of Emergency
Medicine, Mayo Clinic, Rochester,
MN
Amy O’Neil, MD, MPH, Senior
Resident, Emergency Medicine,
Mayo Clinic, Rochester, MN
Peer Reviewer:
Samuel H.F. Lam, MD, RDMS,
FACEP, Attending Physician,
Advocate Christ Medical Center,
Oak Lawn, IL; Clinical Associate
Professor of Emergency Medicine,
University of Illinois at Chicago
Statement of Financial Disclosure
To reveal any potential bias in this publication, and in
accordance with Accreditation Council for Continuing
Medical Education guidelines, we disclose that
Dr. Dietrich (editor), Dr. Skrainka (CME question
reviewer), Dr. Bellolio (author), Dr. O’Neil (author),
Dr. Lam (peer reviewer), Ms. Coplin (executive editor),
and Ms. Kimball (managing editor) report no relation-
ships with companies related to the field of study cov-
ered by this CME activity.
AHC Media
Pediatric Appendicitis
The diagnosis of acute appendicitis remains a challenging conundrum for
the emergency physician. The differential is exceptionally broad and the presen-
tation can vary from vague nausea to classical McBurney’s point tenderness.
Incorporating various imaging modalities in the diagnosis of appendicitis has
drastically reduced the rate of negative appendectomies. However, determining
which patients warrant more extensive imaging requires an astute physician who
maintains a high index of suspicion for the diagnosis. This review will discuss
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.
— Ann M. Dietrich, MD, FAAP, FACEP, Editor
“Almost every surgeon has at one time gone in for an acute appendix when the
real cause of the symptoms was influenza, beginning pneumonia, diaphragmatic
pleurisy, acute gastritis, ureteral calculus, fecal impaction, dysmenorrhea, onset
of menstruation in a girl about puberty, tubercular peritonitis, floating kidney,
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?
Definition and Etiology
Appendicitis is an inflammatory condition of the appendix that can progress
to rupture with suppurative or gangrenous complications if left untreated.1
Though it is frequently encountered by the emergency physician and is the
most common surgical emergency in children, the etiology remains unclear.2
The classic teaching is that obstruction occurs within the lumen of the appen-
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
 Executive Summary
zz The risk of perforation is significantly increased in obese
children, children 0-4 years of age, and patients present-
ing with a longer duration of symptoms.
zz Young children under the age of 2 years can be particu-
larly challenging and may present with fever, irritability,
vomiting, grunting, abdominal pain, diarrhea, right hip
pain, or limp.
zz The Alvarado Score is a 10-point scoring system with
sensitivity ranging from 76-90% and specificity of
72-79%. The Pediatric Appendicitis Score is also a
10-point scoring system with a sensitivity ranging from
57-96% and specificity between 74-97%. They should
be used to supplement decision-making but cannot be
solely relied upon for the diagnosis of acute appendicitis.
zz A meta-analysis by Doria et al found that the pooled
sensitivity and specificity of computerized tomography
(CT) are significantly higher than ultrasonography
(US). The sensitivity of US is directly correlated with
the experience of the operator.
zz A recommended approach to imaging is to begin with
an abdominal US in those patients with intermediate
risk of appendicitis followed by CT or surgical
consultation for equivocal exams or when the
appendix is not visualized.

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

trauma, and diet.5 Many cases of
appendicitis have been confirmed
without any evidence of obstruc-
tion, and the cause of appendiceal
inflammation in these cases remains
unclear.
Epidemiology
Acute appendicitis has an annual
incidence of 37.2 per 10,000
American children between the ages
of 0-14 years.6 The highest fre-
quency is in patients between 10-14
years of age.7,8 The lifetime risk of
acute appendicitis is 8.6% in boys
and 6.7% in girls.2 The incidence of
appendicitis tends to be higher in
white and Hispanic patients than
in African-American and Asian
patients.8 The risk of perforation
is significantly increased in obese
children, children 0-4 years of age,
and patients presenting with a lon-
ger duration of symptoms.8,9,10,11
An increased risk of perforation for
patients living in rural locations and
having lower median household
incomes has been suggested.9
The mortality of appendicitis in
children is very low (< 0.3%); how-
ever, it is associated with significant
morbidity including peritonitis,
sepsis, and paralytic ileus, particu-
larly when complicated by perfora-
tion.12,13,14 A 2005 review by Selbst
et al found that missed appendicitis
is the second most common reason
for malpractice claims filed against
patients.15
Clinical Features
The classic presentation of appen-
dicitis includes fever, abdominal pain
and tenderness, or guarding in the
right lower quadrant. (See Figure 1.)
Approximately one-third of patients
present with atypical symptoms.16
Young children under the age of 2
years can be particularly challenging
and may present with fever, irritabil-
ity, vomiting, grunting, abdominal
pain, diarrhea, right hip pain, or
limp.4 Their variable presentation
is often the cause for delayed diag-
nosis and increased risk of perfora-
tion. One review found that 4.8%
of patients with appendicitis were
missed on initial presentation and
most often misdiagnosed with acute
gastroenteritis, constipation, and
emesis.17
The presence of right lower quad-
rant pain is the most useful clinical
finding in acute appendicitis and
has a positive likelihood ratio (LR+)
of 7.89 (95% confidence interval
[CI], 7.31-8.46).18 The presence of
fever also increases the likelihood
of appendicitis (LR+ 3.4; 95% CI,
2.4-4.8); however, it is not very spe-
cific.4 Periumbilical pain migrating
to the right lower quadrant is less
helpful (LR+ 2.06; 95% CI, 1.63-
2.60). The presence of abdominal
rigidity and rebound tenderness
on exam are moderately strong
positive likelihood ratio of 3.8 and
3.0, respectively.4,18 (See Table 1.)
Patients presenting with symp-
toms for > 24 hours in duration
are more likely to have appendiceal
perforation.19 Those patients are
also more likely to have guarding on
physical exam, while patients with
non-perforated appendix are more
likely to have McBurney’s point ten-
derness.20 The presence and degree
of fever has not been shown to be
reliably associated with an increased
risk of perforated appendix.20,21
Differential Diagnosis
The differential diagnosis for
patients presenting with suspected
appendicitis is broad and contributes
to the challenge of appropriately
identifying children with appendici-
tis. (See Table 2.)
Laboratory Studies
The laboratory evaluation for
acute appendicitis hinges on the
presence of leukocytosis, often
with neutrophil predominance and
inflammatory marker elevation, par-
ticularly c-reactive protein (CRP)
and procalcitonin (PCT). Additional
markers that are more specific to
appendicitis, including 5-hydroxy-
indoleacetic acid (HIAA) in urine,
have recently been evaluated, but
at this point still require addi-
tional research and are not widely
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-
pressible. Inflammatory changes
such as wall thickening, increased
blood flow, echogenic perice-
cal fat stranding, and presence of
appendicolith or free fluid are also
highly suggestive of the diagnosis.14
(See Figure 3.) In approximately
42-47% of US, the appendix is not
visualized and further work-up is
required.38
A meta-analysis by Doria et al
found that the pooled sensitiv-
ity and specificity of CT are sig-
nificantly higher than US.39 (See
Table 5.) The sensitivity of US is
directly correlated with the experi-
ence of the operator.35 One study
by Bachur et al also found that the
sensitivity of US in detection of
appendicitis is increased in patients
who present with longer durations
of symptoms.2 CT detection of
118 Pediatric Emergency Medicine Reports / October 2014 www.ahcmedia.com
appendicitis is not similarly affected As magnetic resonance imaging
by symptom duration. Many studies (MRI) is becoming more widely
have evaluated the effect of obesity available, it may offer an excel-
on visualization of the appendix lent alternative to CT and US for
with US. Conflicting evidence has the diagnosis of appendicitis. MRI
been reported, although there does avoids exposure to radiation while
seem to be a trend toward a higher maintaining excellent test perfor-
rate of non-diagnostic ultrasounds mance. The sensitivity and specific-
in obese patients.10,40,41,42,43 These ity of MRI are 100% and 96-99%,
patients then require CT for further respectively. It has a negative pre-
evaluation, as there is no decrease dictive value of 100% and positive
in sensitivity of CT for patients who predictive value of 83-98%. 44,45 The
are obese.40 greatest challenges of MRI at this
Table 5. 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)
time are limited availability and cost.
A recommended approach to
imaging is to begin with an abdomi-
nal US in those patients with inter-
mediate risk of appendicitis followed
by CT or surgical consultation for
equivocal exams or when the appen-
dix is not visualized.46 This approach
has yielded a sensitivity and speci-
ficity of 98.6% and 90.6%, respec-
tively.47 Institutional studies that
have moved to a protocolized work-
up using this staged approach have
decreased use of CT by at least 50%
and have not found a statistically
increased risk of perforation.48,49
Management
The ED management of appendi-
citis is primarily focused on correc-
tion of dehydration, pain control,
and timely antibiotic administration.
Patients typically present dehydrated
due to anorexia and vomiting and
should have an IV established to
begin rehydration. This can be
accomplished with a 20 mL/kg fluid
bolus of isotonic crystalloid until
clinical signs of dehydration have
resolved. Patients should then be
placed on maintenance fluid at 1-1.5
times the calculated rate.
Ensuring appropriate pediatric
analgesia is frequently overlooked,
as these patients tend to be under-
dosed or do not receive adequate
pain control.29 Analgesia is best
achieved using parenteral narcotics.
Morphine 0.1 mg/kg IV or fentanyl
1 mcg/kg IV are safe and effective
options.
Patients with evidence of non-per-
forated appendicitis should receive
prophylactic antibiotics in the
ED to decrease the risk of wound
infections and intra-abdominal
abscess.50 The bacteria most often
found in appendicitis is Escherichia
coli, followed by Klebsiella pneu-
moniae, Streptococcus, Enterococcus,
and Pseudomonas aeruginosa.51
The American Pediatric Surgical
Association recommends the use of
broad-spectrum antibiotic coverage
using either a single broad-spectrum
agent such a piperacillin-tazobactam
or double-agent therapy with an
www.ahcmedia.com
advanced generation cephalosporin
such as ceftriaxone and metroni-
dazole.52 Cases of uncomplicated
appendicitis often do not require
postoperative antibiotic treat-
ment. Perforated appendicitis
requires a prolonged course with IV
antibiotics.52
The management of appendicitis
is primarily surgical. One study by
Yardeni et al found that patients
taken to the operating room (OR)
within 6 hours of ED triage did not
result in any increase in perforation
rate, length of stay, or complications
compared to patients taken to the
OR between 6 and 24 hours of ED
triage.53 If the patient is hemody-
namically stable without evidence
of septic shock, the patient should
be taken to the OR within 24 hours
of presentation at a time when
resources and staffing are readily
available.
Most cases of non-perforated
appendicitis are treated operatively
and primarily by laparoscopic appen-
dectomy.9 Complications includ-
ing wound infection, abscess, and
bowel obstruction within 30 days of
operating are significantly reduced
when a laparoscopic approach is
used compared to open appen-
dectomy.54,55 A growing body of
evidence has found that pediatric
patients with early appendicitis
may be treated with antibiotics
alone without operative interven-
tion; however, studies with longer
periods of follow-up to determine
risk of recurrence in children are
still needed.56 The Non-Operative
Treatment for Acute Appendicitis
(NOTA) study in adults found
an 83% efficacy rate at 2 years
follow-up.57
Patients with perforated appen-
dicitis are increasingly being
managed nonoperatively with IV
antibiotic therapy. Although this
can be a successful strategy, it car-
ries approximately a 15-25% failure
rate with interval appendectomy
required earlier than scheduled
and hospital re-admissions.58 The
presence of appendicolith increases
the failure rate of non-operative
Pediatric Emergency Medicine Reports / October 2014
management.58,59
Cases of perforated appendicitis
that have developed an abscess or
appendiceal phlegmon are often
managed non-operatively with
percutaneous drain placement and
IV antibiotics followed by inter-
val appendectomy. A prospective
randomized controlled trial by St.
Peter et al found that there was no
significant difference in length of
hospitalization or recurrent abscess
when patients were managed with
drain placement and interval appen-
dectomy compared to patients taken
directly for appendectomy. There
was a trend toward longer operating
times for patients taken for immedi-
ate appendectomy.60
Disposition
Patients need to be stabilized in
the ED initially along with prompt
surgical consultation. The stable
patient may be admitted for appen-
dectomy within 24 hours from pre-
sentation. Those who have evidence
of septic shock require prompt sur-
gical intervention and potential ICU
admission.
Conclusion
Children commonly present
with abdominal pain, which has a
broad differential. Diagnosing acute
appendicitis requires a high degree
of suspicion and a logical approach
to minimize the morbidity associ-
ated with this disease. The judicious
use of diagnostic studies including
ultrasound and CT may further
delineate the clinicians diagnostic
concerns for this condition. Timely
surgical consultation for further
management is a critical aspect to
the acute care of these children.
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26. Andersson RE. Meta-analysis of the
clinical and laboratory diagnosis of
appendicitis. Br J Surg 2004;91:28-
37.
27. Yu CW, Juan LI, Wu MH, et al.
Systematic review and meta-analysis
of the diagnostic accuracy of pro-
calcitonin, C-reactive protein and
white blood cell count for sus-
pected acute appendicitis. Br J Surg
2013;100:322-329.
28. Chen CY, Zhao LL, Lin YR, et al.
Different urinalysis appearances in
children with simple and perfo-
rated appendicitis. Am J Emerg Med
2013;31:1560-1563.
29. Tsze DS, Asnis LM, Merchant RC,
et al. Increasing computed tomogra-
phy use for patients with appendicitis
and discrepancies in pain manage-
ment between adults and children:
An analysis of the NHAMCS. Ann
Emerg Med 2012;59:395-403.
30. Bachur RG, Hennelly K, Callahan
MJ, Monuteaux MC. Advanced
radiologic imaging for pediatric
appendicitis, 2005-2009: Trends and
outcomes. J Pediatr 2012;160:1034-
1038.
31. Adibe OO,Amin SR, Hansen EN, et
al. An evidence-based clinical proto-
col for diagnosis of acute appendi-
citis decreased the use of computed
tomography in children. J Pediatr
Surg 2011;46:192-196.
32. Didier RA, Vajtai PL, Hopkins KL.
Iterative reconstruction technique
with reduced volume CT dose index:
diagnostic accuracy in pediatric acute
appendicitis. Pediatr Radiol 2014;
Jul 5 [Epub ahead of print].
33. Ladd MR, Neff LP, Becher RD, et
al. Computerized tomography in
the workup of pediatric appendicitis:
Why are children scanned? Am Surg
2012;78:716-721.
34. Raval MV, Deans KJ, Rangel
SJ, et al. Factors associated with
imaging modality choice in chil-
dren with appendicitis. J Surg Res
2012;177:131-136.
35. Mittal MK, Dayan PS, Macias CG, et
al. Performance of ultrasound in the
diagnosis of appendicitis in children
in a multicenter cohort. Acad Emerg
Med 2013;20:697-702.
36. Kaiser S, Finnbogason T, Jorulf
HK, et al. Suspected appendi-
citis in children: Diagnosis with
contrast-enhanced versus non-
enhanced Helical CT. Radiology
2004;231:427-433.
37. Laituri CA, Fraser JD, Aguayo P, et
al. The lack of efficacy for oral con-
trast in the diagnosis of appendicitis
by computed tomography. J Surg Res
2011;170:100-103.
38. Jaremko JL, Crockett A, Rucker D,
Magnus KG. Incidence and signifi-
cance of inconclusive results in ultra-
 sound for appendicitis in children
and teenagers. Can Assoc Radiol J
2011;62:197-202.
39. Doria AS, Moineddin R,
Kellenberger CJ, et al. US or CT
for diagnosis of appendicitis in chil-
dren and adults? A meta-analysis.
Radiology 2006;241:83-94.
40. Abo A, Shannon M, Taylor G,
Bachur R. The influence of body
mass index on the accuracy of ultra-
sound and computed tomography in
diagnosing appendicitis in children.
Pediatr Emerg Care 2011;27:731-
736.
41. Butler M, Servaes S, Srinivasan A,
et al. US depiction of the appendix:
Role of abdominal wall thickness and
appendiceal location. Emerg Radiol
2011;18:525-531.
42. Sulowski C, Doria AS, Langer JC, et
al. Clinical outcomes in obese and
normal-weight children undergoing
ultrasound for suspected appendicitis.
Acad Emerg Med 2011;18:167-173.
43. Yigiter M, Kantarci M, Yalcin O,
et al. Does obesity limit the sono-
graphic diagnosis of appendicitis
in children? J Clin Ultrasound
2011;39(4):187-190.
44. Goldin AB, Khanna P, Thapa M, et
al. Revised ultrasound criteria for
appendicitis in children improve
diagnostic accuracy. Pediatr Radiol
2011;41:993-999.
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
appendicitis. AJR Am J Roentgenol
2012;198:1424-1430.
46. Rosen MP, Ding A, Blake MA, et
al. ACR appropriateness criteria
right lower quadrant pain-suspected
appendicitis. J Am Coll Radiol
2011;8:749-755.
47. Krishnamoorthi R, Ramarajan N,
Wang NE, et al. Effectiveness of
a staged US and CT protocol for
the diagnosis of pediatric appendi-
citis: Reducing radiation exposure
in the age of ALARA. Radiology
2011;259:231-239.
48. Peña BM, Taylor GA, Fishman SJ,
Mandl KD. Effect of an imaging
protocol on clinical outcomes among
pediatric patients with appendicitis.
Pediatrics 2002;110:1088-1093.
49. Toorenvliet BR, Wiersma F, Bakker
RF, et al. Routine ultrasound and
limited computed tomography for
the diagnosis of acute appendicitis.
World J Surg 2010;34:2278-2285.
50. Andersen BR, Kallehave FL,
Andersen HK. Antibiotics versus
www.ahcmedia.com
placebo for the prevention of post- 54. Gasior AC, St Peter SD, Knott
operative infection after appendicec- EM, et al. National trends in
tomy. Cochrane Database Syst Rev approach and outcomes with appen-
2005;CD001439. dicitis in children. J Pediatr Surg
51. Chen CY, Chen YC, Pu HN, et al. 2012;47:2264-2267.
Bacteriology of acute appendicitis 55. Lee SL, Yaghoubian A, Kaji A.
and its implication for the use of Laparoscopic vs open appendectomy
prophylactic antibiotics. Surg Infect in children: Outcomes comparison
(Larchmt) 2012;13:383-390. based on age, sex, and perforation
52. Lee SL, Islam S, Cassidy LD, et al. status. Arch Surg 2011;146:1118-
Antibiotics and appendicitis in the 1121.
pediatric population: An American 56. Armstrong J, Merritt N, Jones S, et
Pediatric Surgical Association al. Non-operative management of
Outcomes and Clinical Trials early, acute appendicitis in children:
Committee systematic review. J Is it safe and effective? J Pediatr Surg
Pediatr Surg 2010;45:2181-2185. 2014;49:782-785.
53. Yardeni D, Hirschl RB, Drongowski 57. Di Saverio S, Sibilio A, Giorgini E, et
RA, et al. Delayed versus immediate al. The NOTA Study (Non Operative
surgery in acute appendicitis: Do we Treatment for Acute Appendicitis):
need to operate during the night? J Prospective study on the efficacy and
Pediatr Surg 2004;39:464-469. safety of antibiotics (amoxicillin and
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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
the rate of negative appendec-
tomies and led to a decrease
in perforation rate.
7. Which of the following is true
regarding ultrasound (US) in
the diagnosis of suspected acute
appendicitis?
a. US has a greater sensitivity
than CT in the diagnosis of
appendicitis.
b. The accuracy of US for diag-
nosing acute appendicitis is
approximately equal to the
accuracy of CT.
c. The diagnosis of appendicitis
on US is demonstrated by a
dilated appendix > 6 mm
that is tender and non-
compressible.
d. MRI is a better alternative to
US in children.
8. Which of the following is the
appropriate management of a
child with acute appendicitis?
a. The emergency department
management of appendicitis
is only about making the
diagnosis.
b. The emergency department
management of appendicitis
is primarily focused on
diagnosis, appropriate
consultation, correction of
dehydration, pain control
and timely antibiotic
administration.
c. There is no role for the
emergency department in the
management of appendicitis,
as it is primarily surgical
management.
d. Analgesia is not needed in
these patients as they will be
going to the operating room
under anesthesia.
9. Which one is appropriate in the
management of a child with acute
appendicitis?
a. Ensuring appropriate analgesia
with parenteral narcotics
b. Beginning with 1-1.5x main-
tenance fluids for children
c. Giving antibiotics post-oper-
atively to decrease the risk of
wound infections and intra
abdominal abscess
d. Initiated fluid replacement
with dextrose containing fluid
to prevent hypoglycemia
10. Which of the following is true
regarding disposition of a patient
with acute appendicitis?
a. Patients need to be stabilized
in the ED initially along
with prompt surgical
consultation.
b. The stable patient may be dis-
charged to home with outpa-
tient surgical follow-up.
c. Those who have evidence of
septic shock can be treated
with IV antibiotics alone.
d. Patients with perforated
appendicitis should always be
taken directly to the OR.

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

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

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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.