Appendicitis

Incidence
 Appendicitis is the most common surgical emergency in children.
 The overall lifetime risk is estimated to be around 8%with an age peak during 10 years.
 There is a slight male predominance (60%).

Pathophysiology and natural history

 The appendix represents a long, true diverticulum with a narrow lumen.

 The appendix serves as a reservoir for normal intestinal flora and has the highest concentration of
gut-associated lymphoid tissue (GALT) in the intestine. 
 appendectomy has been associated with a reduced risk of developing ulcerative colitis and an
increased risk of developing severe Clostridium difficile-associated colitis .

Etiology

 Half the cases arise from luminal obstruction from stool fecaliths.
 lymphoid hyperplasia or neoplasm. 
 A family history imparts a nearly threefold increased risk, with genetic factors accounting
for 30% of the risk of developing appendicitis. 
 resolution without treatment can occur as is seen in cases of relapsing or chronic appendicitis.
Perforation rates have been reported to be as high as 82% in children younger than 5 years and
nearly 100% in 1-year-old children. 
 Bacteria such as Yersinia, Salmonella, and Shigella, viruses such as mumps, Coxsackie B, and
adenovirus.
Diagnosis
1.History 
(Clinical features)
Common
1. Anorexia 
Problem in
2. vague periumbilical pain
School Age
3. migrating to the right lower quadrant
Children
4. Nausea & vomiting 
5. Diarrhea is often seen with perforated appendicitis
6. Fever is common and usually of low grade in acute appendicitis

 This pain is of visceral nerve origin and is referred to the common dermatome of the 8th–10th thoracic dorsal ganglia,
which results in the sensation of periumbilical pain. It is important to remember that inflammation of any midgut
derivative will cause this same symptom.
 The pain becomes localized to the right lower abdomen when the inflammation on the appendix irritates the local
peritoneum, which has potent somatic sensation. 

 In general, gastroenteritis is more likely with a history of repeated episodes of vomiting and diarrhea starting at a similar time
or preceding the onset of the pain. This is especially true when the abdominal pain is the minor symptom, it is not localized, and
there is no focal tenderness

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 A positive psoas sign is often suggestive of a retrocecal
appendicitis
2. Examination
1. RLQ tenderness is exhibited by objective demonstration of pain such as wincing, moving, or flexing
when gentle pressure is applied in the right lower quadrant (RLQ) near the McBurney point.
2. the Rovsing sign, which is RLQ pain that results from palpation of the left lower abdomen.
3. The obturator sign is RLQ pain with flexion and internal rotation of the right hip.
4. A psoas sign is RLQ pain when the patient is in the left decubitus position and the right leg is
extended.
5. The Dunphy sign is increased RLQ pain with coughing.
6. Markle (heel jar) test is pain with dorsiflexion of the right foot.

A palpable mass in the RLQ is difficult or nearly impossible to identify in the patient with guarding or rigidity. The
mass often becomes evident on the operating table after anesthesia has been induced. 

 The classic picture outlined previously with progression of pain to tenderness and anorexia to vomiting
actually occurs in fewer than half of patients.
 50% of those with appendicitis presented without pain migration,
 50% with-out rebound tenderness,
 40% without anorexia
 29% without nausea.
 Bowel sounds are also quite nonspecific (and may be absent if perforation has occurred) compared with
informs being hyperactive with gastroenteritis
 rectal examination is a traumatizing and nonspecific adjunct that is unlikely to contribute to the evaluation . 
.  
Appendicitis Risk Scores 
 The Alvarado Score is similar to the Pediatric Appendicitis Score (PAS), which is specifically designed
for children age 4–15 years. 
 The Appendicitis Inflammatory Response (AIR) Score may be preferable in young children because
the Alvarado Score requires children to identify nausea, anorexia, and migration of pain. 
 The Alvarado Score compares more favorably to the AIR Score in adolescents.
 The PAS and the Alvarado Score have been investigated the most thoroughly, and both had initially
shown sensitivity, specificity, negative predictive value (NPV), and positive predictive value (PPV)
over 90%.
 The scoring systems are even less reliable in adolescent females, which demonstrates the necessity
for investigation beyond the scoring system in these patients.

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3. laboratory tests ((ordered are those intended to assess the overall state of inflammation in the patient, including))

 white blood cell (WBC) count

 absolute neutrophil count (ANC)
 C-reactive protein (CRP).
 Mild elevation of the leukocyte count (11,000- 16,000/mm3) is the most common scenario. 
 A markedly elevated leukocyte count suggests perforation or another diagnosis.
 However, a normal leukocyte count does not exclude appendicitis as the possible diagnosis.
 Urine is usually free of bacteria, and a few or a moderate number of red or white blood cells is
common as the inflammation can affect the ureter or bladder. Because patients are often
dehydrated, concentrated urine and ketonuria are expected from decreased oral intake and the
release of insulin-antagonizing inflammatory mediators.
 Serum electrolytes, liver enzymes, and liver function studies are usually normal

4.Imaging studies However, these studies almost never serve as the

Plain films may demonstrate a fecalith in 5 - 15% of patients  determinant for a management decision and are
not recommended unless bowel obstruction, mass, or
A. Ultrasound (US)  free peritoneal air is suspected. 
The common US signs of appendicitis include 
 a fluid-filled.
 noncompressible appendix. the sensitivity and specificity of US
 a diameter >6 mm. were 88% and 94%, respectively
 an appendicolith.
 periappendiceal or pericecal fluid.
 increased periappendiceal echogenicity caused by inflammation .
B. Computed tomography (CT)
 generally accurate 
 the first choice. CT scan should be used if US does not provide sufficient information to make a
diagnosis

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 C. Magnetic resonance imaging (MRI)
Advantages 
 nonradiation alternative to CT and is extremely accurate for the diagnosis of appendicitis. 
 Overall sensitivity and specificity are 97% 
the most common diagnosis made in the
Disadvantages  face of missed appendicitis is reported to
 include lack of availability,  be gastroenteritis)
 high cost, and the potential need for sedation 
Differential Diagnosis of Acute Appendicitis

Gastrointestinal Genitourinary Other

Mesenteric adenitis
Crohn disease Tract Urinary tract Pneumonia
Meckel diverticulitis infection Henoch–Schönlein
Hydronephrosis purpura
Cecal diverticulitis
Ureteral calculi
Viral gastroenteritis Kawasaki disease
Wilms tumor
Regional bacterial Ovarian torsion Omental Torsion
enteritis (Yersinia Ruptured ovarian cyst Porphyria
and Campylobacter Salpingitis Sickle cell anemia
in particular) Testicular torsion
Cholecystitis Lymphoma
Pancreatitis Vasculitis
Typhlitis (leukemia) Parasitic infection

The treatment of appendicitis

Treatment universally begins with IV fluids
and broad-spectrum antibiotics. 
Nonperforated appendicitis

APPENDECTOMY
 The historic standard for management of appendicitis has been urgent appendectomy.
 Although the operation used to be considered an emergency, this is no longer the case.
 antibiotics alone can treat appendicitis the operation can be performed the next day after initiation
of antibiotics without concern for a negative impact.
 delays of 12–24 hours were not associated with increased rates of perforation or postoperative
abscess.
 delay was not associated with an increased risk for wound infection, intra abdominal abscess,
reoperation, or readmission.
 In addition, appendectomies during the night place stress on the family, the surgeon, and the
hospital, and are no longer justified.
 Most appendectomies today are performed laparoscopically, currently well over 90% compared
with 20% twenty years ago.

Advantages 
 no difference in abscess risk between the open and laparoscopic 
 laparoscopy has been shown to decrease wound infections In addition, the clinical importance of
port site infections is relatively small.
 Also, the laparoscopic operation has been found to reduce the risk of postoperative adhesive small
bowel obstruction

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After appendectomy for no perforated appendicitis, current evidence suggests an additional dose of antibiotics is not necessary or
recommended. Recently, there has been a movement to discharge these patients without an additional night in the hospital . 

NONOPERATIVE MANAGEMENT 
 Managing children with uncomplicated appendicitis without an appendectomy is a treatment choice.
 Avoiding an operation avoids an unnecessary anesthetic for those patients who do not have appendicitis. 
 NOM had fewer complications, better pain control, and shorter sick leave, but with a high rate of recurrence
compared with initial appendectomy. 

A challenge to no operative management (NOM) of acute appendicitis in children is parental misperception that a delay in
appendectomy is likely to lead to a ruptured appendix, with a high likelihood of major complications or death. 

indicators for failure of NOM

 An appendicolith has been an adverse indicator for antibiotic-only treatment
 abdominal pain for >48 hours
 WBC count >18,000 and/or pronounced bandemia;
 CRP >4 mg/dL
 signs of bowel obstruction, abscess, or phlegmon on imaging. 

Perforated Appendicitis 

 perforation is an identifiable hole in the appendix or a fecalith in the abdomen, with a high risk of
developing an abscess (20%).
 A retrospective comparative study found once-a-day dosing with ceftriaxone and metronidazole was
as effective as traditional triple therapy and less costly. 
 A multicenter case-control study suggests that the patient who is clinically well by postoperative day
3 is unlikely to develop an abscess. 
 A randomized trial found early transition to oral antibiotics to be as effective as a prolonged course
of IV antibiotics.
 A follow-up prospective observational study found that further oral antibiotic therapy was not
needed if the patient is eating and has a normal WBC count. 

patients will require antibiotic therapy postoperatively at least until clinical resolution. 

 triple antibiotic therapy (ampicillin, gentamicin, and clindamycin).

 Monotherapy with piperacillin/ tazobactam for intra-abdominal infections .
 cefotaxime, with metronidazole. 

Surgical management

Three general strategies are applied for the treatment of perforated appendicitis: 
 antibiotics only.

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 antibiotics followed by interval appendectomy.
 and appendectomy on presentation. 

The rationale for treating initially with antibiotics is to avoid a difficult operation during the peak of the
inflammatory process, which can make the operation more difficult. After treating the acute
presentation with antibiotics, an operation becomes more straight forward , and then the decision
becomes whether to perform the appendectomy or not.
 Those who do not perform an appendectomy think there is a low risk of recurrent
appendiciti s, is 8–14%. 
 In the anti bioti c and observati on group, 12% recurred with appendiciti s in the one-
year ti me.
 These results were not diff erent from the rate of complicati ons in the
anti bioti cs/interval appendectomy group, and the authors concluded that anti bioti cs
and observati on may be a reasonable approach.
 Several studies have compared early versus delayed appendectomy for perforated
appendiciti s,
 Those undergoing a delayed operati on had fewer overall complicati ons, wound
infecti ons, abdominal/pelvic abscesses, ileus/bowel obstructi ons, and reoperati ons.
 No signifi cant diff erence was found in the durati on of the initi al hospitalizati on, the
overall durati on of hospitalizati on, and the durati on of IV anti bioti cs. 
 increase in the postoperati ve development of an abscess resulti ng from the use of
irrigati on.

Abscess on Presentation 

 In the past, the operations were difficult and required large incisions with high morbidity. 
 Treatment of the abscess, with percutaneous aspiration with or without placement of a drain
followed by interval appendectomy when the inflammation has resolved, allows for a less
morbid operation.
 culture of the fluid has been shown to be of no benefit it is routine clinical practice to flush
the drains once or twice a day with saline to maintain patency. 
 we do not recommend the routine use of instilling tissue plasminogen activator tPA into
abdominal abscesses. 

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