Appendicitis

MASHAEL ALOMARI F1
 ..Objectives
•Anatomy.
•Presentation.
•Differential Diagnosis.
•Diagnosis.
•Management.
•Pitfalls.
Acute appendicitis is one of the most common causes of abdominal pain and is
the most frequent condition leading to emergent abdominal surgery in children.
The incidence between birth and age 4 years is 1-2 cases per 10,000 children per
year. The incidence increases to 25 cases per 10,000 children per year between
10 and 17 years of age. The male-to-female ratio is approximately 2:1.
..Anatomy
A narrow, hollow tube structure with
larg lymphoid tissue aggregation in its
walls, suspended from the terminal
ileum by the mesoappendix.

Unknown function.
..Presentation

• Acute appendicitis: 60 - 65%

• Perforated appendicitis: 25 - 30%
• Perforated appendicitis with
well-defined abscess (5-7 day
history): 5 - 10%
Classic signs of appendicitis on
physical examination are:
•Local tenderness with some rigidity of the abdominal wall at or near McBurney
point.
•Rovsing sign: Pain in the right lower quadrant on palpation of the left side.
•Obturator sign: Pain on internal rotation of the right hip.
•Iliopsoas sign: Pain on extension of the right hip, which is found in retrocecal
appendicitis.
..Differential Diagnosis
..Scoring Systems
Diagnosis..
Laboratory Studies:
• Complete Blood Count: White Blood Cell Count
• C-Reactive Protein
• Urinalysis
• Electrolyte levels
• Pregnancy Testing

Radiologic Studies:
• Ultrasound
• Computed Tomography
The optimal cutoff value for WBC count was 12,000 cells/mcL, yielding a sensitivity of 71% (95% confidence
interval [CI], 61%-80%) and a specificity of 66% (95% CI, 55%-77%). Note that the WBC count should not be
relied upon to rule disease in or out. It is important to remember that many other etiologies of abdominal pain
especially infectious causes will cause an elevation in the WBC countt.

WBC count had a better diagnostic value than the CRP on day 1 of illness in the diagnosis of acute appendicitis
but not in the diagnosis of perforated appendicitis. An optimal cutoff value of 3 mg/dL (30 mg/L) yielded a
sensitivity of 70% (95% CI, 60%-79%) and a specificity of 65% (95%CI, 53%-75%). Note that the WBC count and
CRP are nonspecific findings; if suspicion for appendicitis is high, the emergency clinician should still proceed
with imaging.
For complicated appendicitis, CRP has the highest degree of diagnostic accuracy. If WBC and CRP values are
within normal limits, even though diagnosis of AA can not be ruled out, diagnosis of complicated appendicitis is
a very remote possibility. The diagnosis of appendicitis should be made primarily based on clinical examination,
and obviously more specific and systemic inflammatory markers are needed. Combined use of cut-off values of
WBC(≥13100/𝜇L) and CRP (≥1.17mg/L) yields a higher sensitivity and NPV for the diagnosis of complicated
appendicitis.
Over the course of the past five years, use of US as the first diagnostic imaging study in the evaluation of children
with pediatric appendicitis has increased significantly. The use of CT as the first study has decreased, but the use of
CT at some point during the evaluation remains high, at over 40% in the most recent year of the study.

Over a third of these CT scans were performed after a non-diagnostic US, suggesting that quality of studies may be
a significant driver for the use of radiation-based imaging in children with appendicitis. Overall, there is a significant
gap between US and CT accuracy in our state, as well as high levels of variability of US accuracy between hospital
sites.
..Management
Pitfalls..
•Although it is more common for older kids to be diagnosed with appendicitis, it’s still a possible
diagnosis for a less than a 2 years old child.
•Appendicitis will always present with a right sided flank pain?
•Randomized trials have shown that the use of opioid analgesia in children being evaluated for suspected
appendicitis does not mask significant findings on abdominal examination or delay diagnosis.
•We shouldn’t involve the surgeon until we’re absolutely sure the child has appendicitis?
Summary..
•In general the diagnosis of acute appendicitis is always clinical, investigations
are helpful when the clinical diagnosis is uncertain.
•Appendicitis presents a special diagnostic dilemma in the pediatric patient.
The clinical manifestations can vary from nonspecific to the typically expected.
•Scoring Systems provide measurably useful diagnostic information in
evaluating children with suspected appendicitis, but can’t be used in clinical
practice to determine the need for surgery.
•Early involvement of the surgeons improves the outcomes.
Shokraaaan =D
NO Qs PLEASE!! -__-