APPENDICITIS
Maaha Usmani
Family medicine
Liaquat National hospital
14 years old girl visits staff clinic with his parents, complaining of being unable to eat since
morning. She claims of “feeling unwell” since morning. Her mother adds that she had 2
episodes of vomiting since morning and she feels certain that she has a fever.
You find the child irritated, dehydrated with sunken eyes, a dry tongue and forehead skin
‘pinch’ yielding decreased skin turgor. You order the vital signs quickly to be recorded and they
confirm a high pulse of 102bpm, a blood pressure of 100/60, R/R of 22br/min and fever(100 F)
Systemic examination reveals only non specific abdominal pain with decreased bowel sounds.
Rebound tenderness is positive.
Next step?
_____________
RULING IN SIGNS FOR
ADULTS
1. RIGHT LOWER QUADRANT PAIN
2.ABDOMINAL RIGIDITY
PERIUMBLICAL PAIN RADIATING TO RIGHT LOWER QUADRANT
RULING IN SIGNS IN
CHILDREN
ABSENT/DECREASED BOWEL SOUNDS
POSITIVE OBTURATOR SIGN
POSITIVE ROVSING SIGN
RISK STRATIFICATION
Low
Moderate
High
By means of
The ALVARADO SCORE
PAEDIATRIC APPENDICITIS SCORE
APPENDICITIS INFLAMMATORY RESPONSE SCORE
Samuel M. Pediatric appendicitis score. J Pediatr Surg.
2002;37:877-881.
IMAGING OF CHOICE
Ultrasound (US) should be the first imaging modality for diagnosing
acute appendicitis (AA). Primary US for AA diagnosis will decrease ionizing radiation
and cost. Sensitivity of US to diagnose AA is lower than of CT/MRI. ... Complementary
MRI or CT may be performed if diagnosis remains unclear
TREATMENT
Intravenous antibiotics may be considered 1st line in selected
patients(Cefoxitime,cefotatan)
Pain control with opioid, NSAIDs and acetaminophen
W O N T H E
AT I SNE
WH
TOPI C … ?
A meta-analysis of five randomized controlled trials found that
antibiotic treatment for adults with appendicitis resulted in
decreased complications, less sick leave or disability, and less
need for pain medication compared with initial appendectomy.
However, 40% of patients who received antibiotic therapy required
appendectomy within one year.
In a study of 375 children, risk factors for appendiceal perforation
included fever, vomiting, longer duration of symptoms, elevated C-
reactive protein level or white blood cell count, and ultrasound
findings of free abdominal fluid, visualized perforation, or a mean
appendix diameter of 11 mm or more.
IMPORTANT
CONSIDERATIONS
CHILDREN AND APPENDICITIS
Signs and symptoms may be atypical especially in young because children localize pain poorly
and signs of peritonitis can be difficult to illicit.
If unsure of diagnosis, and child looks unwell, admit.
If unsure of diagnosis and child looks well, either arrange for a later review
OR
Ask the carer to contact you in case of deterioration /change of symptoms
MESENTERIC ADENITIS
Mesenteric adenitis may mimic appendicitis, presenting as abdominal pain, after urinary tract
infection. Check midstream urine to exclude UTI.
IF guarding, rebound tenderness or any of the previous mentioned signs are found, send for
surgical assessment.
Treatment is simple analgesia and fluids. If it does not settle in 1-2 weeks, refer for paediatric
assessment.
APPENDICITIS AND
PREGNANCY
It affects 1:1000 pregnancies. Mortality is high. Perforation is more common(15-20%)
Fetal monitoring is 5-10% for simple appendicitis
30% when perforated.
Due to pregnancy, appendix is displaced-pain is often felt in paraumbilical region or
subcostally.
Admit immediately if suspected.
DEFINITIVE TREATMENT
Laproscopic/laparotomy appendectomy is the standard of care treatment for appendicitis.
THANK YOU AND HAVE A
GREAT DAY… !
