CASE 54

A 15-year-old girl is seen by the pediatrician complaining of abdominal pain and

vomiting. The abdominal pain is periumbilical, started 12 hours prior, is 9 out of 10 on
the pain scale, and is constant, dull, and achy in nature. The pain is aggravated by
walking and changing positions. The acetaminophen her mother gave her did not
reduce the pain, but is diminished only by lying supine. She is not hungry and has had
one episode of nonbilious emesis 2 hours after the onset of the pain and one small,
loose bowel movement. She denies dysuria, urinary frequency, and her last menses a
week ago was normal; she denies having any sexual contact. On examination, she
appears uncomfortable, has a heart rate of 110 beats/min, and a temperature of 100°F
(37°C). The lung fields are clear to auscultation bilaterally. Her abdominal examination
reveals hypoactive bowel sounds, right rectus abdominis muscle rigidity, and
tenderness to palpation, particularly in the periumbilical region. Her pelvic examination
shows neither vaginal discharge nor cervical motion tenderness, but she has some
abdominal tenderness with gentle bimanual palpation. She has pain at the right lower
quadrant when she flexes the right thigh and extends the hip to place her leg into the
stirrup for the bimanual examination.

What is the most likely diagnosis?

What is the next step in the management of this patient?

ANSWERS TO CASE 54:

Appendicitis
Summary: A 15-year-old girl with periumbilical pain of 12-hour duration, followed by
anorexia and emesis. She has no dysuria or sexual activity, and the pain appears
unrelated to her menses. Her physical examination shows a quiet, rigid, tender
abdomen, and positive psoas sign.
• Most likely diagnosis: Appendicitis.
• Next step in management: A surgeon should be consulted once the diagnosis of
appendicitis is suspected. Abdominal ultrasound has high sensitivity for diagnosis
of appendicitis in experienced pediatric centers, but abdominal computed
tomography (CT) is more often used. Ancillary tests include a complete blood
count (CBC) that may show leukocytosis, a metabolic panel (to identify
diabetes, hypercalcemia, abnormal creatinine, transaminitis), pancreatic enzymes,
and a urinalysis to eliminate other causes of the pain. Despite this adolescent’s
 denial of sexual activity, a urine pregnancy test should always be obtained in
postmenarchal females.

ANALYSIS
Objectives
1. Recognize the presenting clinical signs for appendicitis.
2. Know the differential diagnosis for appendicitis.
3. Know the appropriate management for appendicitis.

Considerations
The definitive diagnosis of appendicitis is made once the pathologist finds inflammation
histologically on the appendix specimen obtained by surgical removal. For this patient,
the initial periumbilical abdominal pain followed by anorexia and vomiting suggests
appendicitis. The pain of appendicitis classically begins periumbilically and then
migrates to the right lower quadrant with maximal discomfort at McBurney point.
However, the pain can occur laterally if the appendix is retrocecal or it can become
diffuse if perforation occurs.
If a patient presents early in the disease process, is lacking the characteristic physical
examination findings, has inconclusive imaging findings, and thus has a questionable
diagnosis, the child may be observed and undergo serial abdominal examinations for a
few hours. However, once appendicitis seems likely, surgical management should occur
in a timely fashion; perforation rates exceed 65% if diagnosis is delayed beyond 36 to
48 hours from symptom onset. The most common complications of appendicitis are
wound infection and intra-abdominal abscess or phlegmon formation, all of which occur
more frequently with appendiceal perforation. Other serious complications are sepsis,
shock, ileus, peritonitis, and adhesions causing small bowel obstruction.

APPROACH TO:
Appendicitis

DEFINITIONS
MCBURNEY POINT: The junction of the lateral and middle third of the line joining the
right anterior superior iliac spine and the umbilicus (Figure 54–1); typically this area is of
greatest discomfort in acute appendicitis.
Figure 54–1. McBurney point.

PSOAS SIGN: Irritation of the psoas muscle caused by active right thigh flexion or
passive right hip extension in patients with appendicitis.
OBTURATOR SIGN: Irritation of the obturator muscle caused by passive internal
rotation of the right thigh in patients with appendicitis.
ROVSING SIGN: Palpation of the left lower quadrant causes pain at the right lower
quadrant in patients with appendicitis.

CLINICAL APPROACH
Appendicitis is a common reason for emergent surgery in children. A person’s lifetime
risk of appendicitis has been estimated at 6% to 20%, with the peak incidence in
adolescence and a slight predilection for males. Appendicitis can develop via several
mechanisms but a frequent cause is when the appendiceal lumen becomes obstructed,
leading to vascular congestion followed by ischemia, gangrene, and ultimately
perforation with spillage of contaminated material into the peritoneum. Obstruction can
be caused intrinsically by inspissated fecal material (a fecalith) or by external
compression from enlarged lymph nodes associated with bacterial or viral infections.
A broad differential diagnosis exists for acute abdominal pain in children (Table 54–1).
A thorough history of the illness with close attention to symptoms in other organ
systems can help identify these causes; for example, subacute weight loss, sore throat,
dysphagia, cough, jaundice, rash, vaginal discharge, and arthralgias do not typically
occur with appendicitis. However, diarrhea can be present with appendicitis due to
bowel inflammation or because enteric infection may have led to the initial appendiceal
inflammation. A comprehensive physical examination can identify pharyngitis, tonsillitis,
icterus, a scarlatiniform or purpuric rash, Murphy sign, costovertebral angle tenderness,
cervical motion tenderness, or testicular torsion. Many cases of appendicitis do not
present with characteristic features so tools such as the pediatric appendicitis scale
(PAS) have been developed, but they have not shown an advantage over clinical
experience in reducing perforation.
Table 54–1 • PARTIAL DIFFERENTIAL DIAGNOSIS OF ACUTE ABDOMINAL PAIN IN CHILDREN
BEYOND INFANCY

Appendicitis usually begins with nonspecific symptoms of malaise and anorexia

and then abdominal pain following in a few hours. Localization to the right lower
quadrant may take 12 to 24 hours to appear, and pain will then be made worse with
movement. Observation of the child getting on and off the examination table can be
revealing; children with appendicitis avoid sudden movements. They may walk in a
manner to decrease movement of the right side of the abdomen, such as a shuffle,
refuse to hop off the table, or brace the abdomen against coughing. The abdomen is
inspected, auscultated for bowel sounds, followed by gentle palpation for the area of
maximal tenderness and rigidity. The examination should be done with the area of
tenderness being palpated last. Gentle finger percussion is the best method to
assess for peritoneal irritation (“rebound tenderness”). The utility of a rectal
examination for children with suspected appendicitis is debatable so it is not routinely
performed; it can, however, be helpful for localizing the pain source in a female
adolescent.
Although not a specific finding, leukocytosis with a predominance of
polymorphonuclear cells (a “left shift”) on a CBC supports an inflammatory process.
However, the CBC may be normal in the first 48 hours of the illness. Thereafter, it would
be expected to be greater than 10,000/mm3 and in cases of perforation, it may be
greater than 20,000/mm3. Urinalysis is important to evaluate for glucose and large
ketones or pyuria with nitrites and bacteria because these findings suggest diabetic
ketoacidosis or urinary tract infection respectively. Mild hematuria or pyuria can occur
with acute appendicitis because of irritation of the bladder or ureteral wall. Chest
radiographs eliminate pneumonia as an alternate diagnosis. Plain abdominal
radiographs can be obtained but are infrequently helpful. Psoas shadow obliteration,
right lower quadrant intestinal dilation, scoliosis toward the affected region, and an
appendicolith (seen in 10% of cases) support appendicitis. In a facility experienced in
using ultrasonography in children, ultrasound is the preferred imaging modality
for a child suspected of having appendicitis. It is more sensitive than plain films for
appendicitis and is particularly useful in female adolescents, in whom the differential
diagnosis often includes ovarian cyst rupture or hemorrhage, follicle rupture, torsion, or
PID. Its main limitation is that the appendix cannot always be visualized, which can
occur if the appendix has already perforated, the patient is obese, or if there is a lot of
bowel distention. Therefore, abdominal CT has become the diagnostic test of
choice in most centers because it is readily available and is particularly helpful for
patients who are neurologically impaired, immunosuppressed, or obese, or for
patients in whom perforation is suspected. If pelvic views are included, it can evaluate
for ovarian pathology as the cause of the abdominal pain. Its disadvantages are the
amount of radiation exposure generated, increased cost, and it may give limited
information without the use of contrast.
Electrolyte abnormalities and volume depletion should be corrected preoperatively as
surgery within 48 hours from diagnosis does not influence perforation rate but reduces
the risk of surgical complications. Analgesia should be given because it has been
shown that it does not interfere with identifying the correct diagnosis. Definitive
treatment is surgical removal of the appendix (appendectomy), accomplished
ideally in less than 24 hours from the time of diagnosis. For perforated appendicitis,
initial management consists of intravenous antibiotics and fluid replacement.
Percutaneous catheters can be used to drain any abscess and then appendectomy is
performed at a later time.

CASE CORRELATION
• Myriad conditions may be confused with the abdominal pain of appendicitis. Sickle
cell disease (Case 13) may present as an abdominal pain crisis or with gall
bladder disease. Pneumonia (Case 14) of the lower lobes is classically described
as possibly causing abdominal pain similar to appendicitis. In the smaller child with
significant lead poisoning (Case 25), abdominal pain along with achy joints,
change in behavior, and encephalopathy can be seen. Bacterial enteritis (Case
28), especially when caused by Campylobacter or Yersinia sp., and the
inflammatory bowel disease (Case 53) may cause abdominal pain confused with
appendicitis. While malrotation (Case 34) typically occurs in smaller children, the
presentation with abdominal pain may be similar; as part of the surgical procedure
to correct a malrotation, an appendectomy typically is performed. Diabetic
 ketoacidosis (Case 42) presents in a variety of ways, among which is abdominal
pain; measurement of a serum sugar typically is performed as part of the
evaluation of a patient with possible appendicitis. The patient with severe sore
throat, abdominal pain, and fever may have streptococcal pharyngitis; the later
complication of this condition is poststreptococcal glomerulonephritis (Case 52).

COMPREHENSION QUESTIONS

54.1 A 7-year-old girl has 3 days of right-sided abdominal pain and 1 day of fever
to 102°F (38.9°C). Her mother says that she has also had poor appetite and
two loose stools the day prior. On examination, her temperature is 101.7°F
(38.7°C), heart rate is 130 beats/min, and respiratory rate is 30 breaths/min.
She appears ill and lies motionless on the stretcher. Because of the pain, she
is unable to sit up for lung auscultation or percussion of the costovertebral
angles. She winced as the stretcher is bumped during palpation of the left
abdomen. The abdomen is distended and diffusely tense with hypoactive
bowel sounds. Percussion over all areas of the abdomen elicits tenderness in
the right lower quadrant (RLQ). Which of the following would NOT be indicated
at this time?
A. Abdominal computed tomography (CT)
B. Abdominal radiograph
C. Pediatric surgery consult
D. Intravenous morphine
E. Normal saline bolus
54.2 A 14-year-old girl presents with a 2-day history of abdominal pain, anorexia,
and vomiting and a 1-day history of fever. For which of the following conditions
would exclude appendicitis from the differential diagnosis?
A. She has not passed a stool over the 2 days of illness.
B. She has had diarrhea.
C. Her urine pregnancy test is negative.
D. Her complete blood count (CBC) shows a white blood cell (WBC) count of
8,000/mm3.
E. She has scleral icterus and tender posterior cervical lymph nodes.
54.3 A previously healthy 8-year-old boy presents to the pediatric clinic with 24
hours of worsening abdominal pain, anorexia, and vomiting. The pain is
located in the umbilical region. A CBC reveals a white blood count of 17,000
cells/mm3 with 70% polymorphonuclear cells. A urine dipstick on a clean-catch
specimen shows 1+ leukocytes, trace blood, and trace ketones, but no nitrites
and no bacteria. Which of the following is the most appropriate management at
this point?
A. Obtain a complete chemistry panel and continue to observe him in the
office.
 B. Send the patient immediately to the pediatric hospital for an abdominal
ultrasound.
C. Give him a prescription for trimethoprim-sulfamethoxazole; schedule a
follow-up visit in 2 days to reevaluate the urine.
D. Admit him to the hospital for intravenous antibiotics to treat presumed
pyelonephritis.
E. Schedule a computed tomography scan of the abdomen for the next
morning.
54.4 A 4-year-old girl has 1 day of fever of 102.4°F (39.1°C), anorexia, two
episodes of vomiting, and abdominal pain. Which of the following would NOT
be part of your examination?
A. Inspection of the oropharynx
B. Auscultation of the abdomen
C. Percussion of the abdomen
D. Digital rectal examination
E. Assessment of gait and self-transferring

ANSWERS
54.1 B. This child’s presentation is concerning for appendicitis, and she may have
already perforated. Abdominal CT is the best imaging tool for confirming the
diagnosis, showing any complication, and helping guide management. A
suspected diagnosis of appendicitis warrants a surgery consult. Her current
management should consist of analgesia and volume repletion. Abdominal
radiographs can be included in the evaluation of abdominal pain but is not the
appropriate imaging tool when appendicitis is strongly suspected.
54.2 E. It is not uncommon for appendicitis to cause stool changes, either
obstipation or ileus from the inflammation. Diarrhea can occur by the same
mechanism or may be part of the initial illness that created the appendicitis. A
negative pregnancy test only excludes ruptured ectopic pregnancy as her
diagnosis. The WBC count may be normal in the first 48 hours of acute
appendicitis. Scleral icterus and tender posterior cervical lymph nodes are not
features of appendicitis.
54.3 B. This boy’s symptoms and signs can be caused by appendicitis so prompt
imaging to further confirm the diagnosis is indicated. His urinalysis is not
consistent with a urinary tract infection, especially because he has peripheral
leukocytosis; the urine abnormalities are most likely the result of bladder wall
or ureter irritation caused by an inflamed appendix. Waiting to perform
diagnostic imaging another 24 hours would increase the risk of perforation to
65% or more.
54.4 D. Children with abdominal pain require a comprehensive examination but
rectal examination is rarely indicated. Inspection of the oropharynx will show
 pharyngitis or tonsillitis and her age may prevent her from disclosing that she
has pain in her throat. Auscultation and percussion of the abdomen should
always be done when pain is reported. If you encounter the child supine on the
examination table, it is important to watch the child go through changes in
position, such as sitting up for the lung examination, transferring off the table,
and then her gait.

CLINICAL PEARLS
Acute appendicitis typically causes periumbilical abdominal pain that eventually
migrates to the right lower quadrant. Emesis usually follows, rather than
precedes, the onset of pain.

Surgical management of appendicitis occurs as soon as the diagnosis is suspected

in order to minimize the risk of perforation.

Appendicitis often is not confirmed until surgery. A history and physical

examination, urinalysis, CBC, and abdominal ultrasound or computed tomography
scan are the most useful tools for eliminating other preoperative considerations.

REFERENCES
Aiken JJ, Oldham KT. Acute appendicitis. In: Kliegman RM, Stanton BF, St. Geme III
J, Schor N, Behrman R, eds. Nelson Textbook of Pediatrics. 19th ed.
Philadelphia, PA: WB Saunders; 2011:1349-1355.
Egan JC, Aiken JJ. Acute appendicitis, typhlitis, and chronic appendicitis. In:
Rudolph CD, Rudolph AM, Lister GE, First LR, Gershon AA, eds. Rudolph’s
Pediatrics. 22nd ed. New York, NY: McGraw-Hill; 2011:1473-1474.