Abstract:

One of the most common causes of

surgical abdominal pain among children
is appendicitis. History of present illness
and physical examination are important
in distinguishing appendicitis from other
Clinical
Evaluation of
etiologies of abdominal pain, and surgical
decisions can be made sometimes on
these findings alone. The addition of
laboratory results and various imaging
modalities can help in equivocal cases.
Ultrasound and computed tomography,
Acute
and more recently magnetic resonance
imaging, are beneficial in the diagnosis of
acute appendicitis. The use of clinical
practice guidelines also can be helpful in
Appendicitis
the triage and treatment of children with
abdominal pain. Patients who present

Emily E.K. Murphy, MD*†,

with history or physical examination
findings concerning for appendicitis
should be managed in a stepwise fashion
to facilitate timing of imaging studies and
Loren Berman, MD†‡
surgical consultation. Management

should include early resuscitation, ap-
propriate laboratory testing and imaging
studies, serial examinations, and early
consultation of the surgical team in
suspicious cases.
Keywords:
appendicitis; abdominal pain;
children
A
bdominal pain is a common complaint in the pediatric
emergency department. Most often, children with
abdominal pain do not require surgical evaluation or
intervention, but approximately 11% undergo surgery. 1
One of the most common surgical causes of abdominal pain is
acute appendicitis. In this article, we present 2 cases of acute
appendicitis, one complicated and discuss the clinical evaluation
and management of appendicitis in children.

*Christiana Care Health System, Department

of Surgery, John H. Ammon Medical Education
Center, 4755 Ogletown–Stanton Rd, Suite
2E70B, Newark, DE, 19718; †Nemours AI
DuPont Hospital for Children, Department of
Pediatric General Surgery, 1600 Rockland Rd,
Wilmington, DE, 19803; ‡Sidney Kimmel
Medical College, Thomas Jefferson University,
1025 Walnut St, Philadelphia, PA 19107.
Reprint requests and correspondence:
Emily EK Murphy, MD, Nemours AI DuPont
Hospital for Children Department of
Pediatric General Surgery, 1600 Rockland
Rd, Wilmington, DE 19803.
(E-mail: emimurphy@christianacare.org
(E.E.K. Murphy),
loren.berman@nemours.org (L. Berman))
1522-8401
© 2014 Elsevier Inc. All rights reserved.
CASE 1
A 7-year-old boy presented to the emergency department with a
3-day history of abdominal pain, which began in the periumbilical
region and then localized to the right lower quadrant. He also
complained of fever, anorexia, and one episode of emesis. He had
no medical history. On physical examination, he was tender in the
right lower quadrant with guarding. Laboratory values
were significant for a white blood cell (WBC) count of 17.6 with
76% neutrophils (reference range, WBC 4.6-9.8 K/μL; neutrophils,
22-56%). C-reactive protein (CRP) was 5.8 mg/dL (reference
range, 0-0.9 mg/dL). Ultrasound (US) of the right lower quadrant
demonstrated a 9.1-cm blind-ending structure in the right lower
quadrant with a hyperemic wall, which was interpreted as being
consistent with acute appendicitis (Figure 1). After preoperative
antibiotics were given, he underwent an uneventful laparoscopic
appendectomy for acute nonperforated appendicitis. The patient
had an uneventful recovery and was discharged home
postoperative day 1.

CLINICAL EVALUATION OF ACUTE APPENDICITIS / MURPHY AND BERMAN • VOL. 15, NO. 3 223
224 VOL. 15, NO. 3 • CLINICAL EVALUATION OF ACUTE APPENDICITIS / MURPHY AND BERMAN
A B
Figure 1. Ultrasound demonstrating acute appendicitis. A and B, Ultrasound right lower quadrant. Seven-year-old boy who presented with
a 72-hour history of abdominal pain that now localizes to the right lower quadrant. Ultrasound demonstrated acute wall thickening and
dilation up to 9.1 mm.
HISTORY
Patients with appendicitis typically present with a
history of abdominal pain that starts in the
periumbilical region and then migrates to the right
lower quadrant. The pain usually starts insidiously,
is persistent, and worsens over time. Waxing and
waning pain is usually suggestive of other causes of
abdominal pain. History may include fever, nausea
with or without vomiting, and anorexia. When
evaluating young children with abdominal pain, it
can be particularly difficult to determine the onset
and duration of symptoms, but it can be helpful to
ask parents or guardians, when they last noticed
their child at a normal level of activity. Practitioners
should elicit a history of diarrhea, cough, sore
throat, myalgias, rhinorrhea, and sick contacts to
evaluate for the potential presence of a viral
infection that might mimic appendicitis. It is also
important to ask about a history of constipation,
which can cause acute abdominal pain. The
perimenarchal female should be asked about her
menstrual status and sexual history.
PHYSICAL EXAMINATION
Children with acute appendicitis are usually less
active than their baseline, lying still on the
stretcher. Patients tend to be most tender at
McBurney’s point, which is one-third of the way
between the anterior iliac spine and the umbilicus.
On physical examination, patients might also
demonstrate a positive Rovsing sign, in which
palpation of the left lower quadrant causes pain in
the right lower quadrant; obturator sign, in which
flexion and internal rotation of the right hip causes
pain in the right lower quadrant; and psoas sign, in
which right lower quadrant pain is caused by
extension of the right leg. 2 Any irritation of the
peritoneum can cause acute abdominal discomfort.
Having the patient ambulate or jump up and down
or even jostling the stretcher should elicit abdom-
inal pain in the child with acute appendicitis. The
examination of the child being evaluated for
appendicitis should be complete. Nasal congestion,
tonsilar erythema or exudates, or asymmetric
breath sounds might suggest a different etiology of
abdominal pain.
Depending on the duration of symptoms, the child
with acute onset abdominal pain concerning for
appendicitis might also have symptoms of dehydra-
tion with tachycardia, tachypnea, or dry mucus
membranes. Treating the dehydration can make the
child more comfortable, although in the case of
appendicitis, it should not completely relieve the
abdominal pain.
DIFFERENTIAL DIAGNOSIS
Viral gastroenteritis is the most common disease
state seen in children who are being evaluated
for appendicitis. Children with gastroenteritis
typically present with nausea, vomiting, and ab-
dominal pain, but they also tend to have concurrent
diarrhea, which is less common in appendicitis.
Right lower quadrant tenderness can result from
mesenteric adenitis, which is inflammation of lymph
nodes in the mesentery of the terminal ileum, or
from constipation.
Other infectious etiologies can also cause abdom-
inal pain. Pneumonia and streptococcal pharyngitis
can present with nausea, vomiting and abdominal
pain, and few if any, primary respiratory symptoms.
Urinary tract infections typically present with
urgency, hesitancy, frequency, and burning with
urination, but abdominal pain may be the chief
complaint. Ascending infection can cause pyelone-
phritis, which often presents with fever, costover-
tebral angle pain, and nausea or vomiting. Urinalysis
is the initial test in evaluating a child with suspected
 CLINICAL EVALUATION OF ACUTE APPENDICITIS / MURPHY AND BERMAN • VOL. 15, NO. 3 225
urinary tract infection or pyelonephritis, but uri-
nalysis results can be misleading as acute appendi-
citis can also cause pyuria. Although kidney stones
are uncommon in pediatric populations, they can
present as abdominal discomfort, which often
radiates to the groin.
Noninfectious entities may also mimic appendi-
citis. A torsed appendix epiploicae, which occurs
when a fatty pedicle arising from the colon twists on
itself and becomes ischemic as well as an omental
infarct may present with acute abdominal pain.
These diagnoses can be identified with computed
tomography (CT) or magnetic resonance imaging
(MRI) but may be discovered during an operation for
acute appendicitis when the appendix has a normal
appearance. 3 It is ideal to identify these diagnoses
before surgery because they tend to be self-limited,
although resection does lead to resolution of
symptoms. 4
The evaluation of abdominal pain in the perime-
narchal female can be particularly difficult.
Mittelschmertz, which is pain at ovulation, can be
debilitating for some women. A ruptured ovarian
cyst or ovarian torsion can also mimic appendicitis,
but pain tends to be more sudden and sharp than the
gradual worsening of appendicitis. It is important to
obtain a sexual history because adolescent girls may
complain of abdominal and pelvic pain with ectopic
pregnancy or sexually transmitted infections.
LABORATORY EVALUATION
Laboratory findings can be helpful in distinguishing
appendicitis from other causes of right lower quad-
rant pain. An elevated WBC count suggests inflam-
mation, infection, or an acute stress reaction.
Although a high WBC count may be nonspecific, a
WBC count of less than 8000/μL has been used as a
cutoff to help reduce the rate of negative appendec-
tomies. 5 The differential of the WBC count may help
distinguish between bacterial, viral, and parasitic
infections—the child with acute appendicitis tends to
have an elevated neutrophil percentage. Urinalysis is
useful in distinguishing urologic etiologies of abdom-
inal pain. C-reactive protein levels can also support
the clinical diagnosis of acute appendicitis, although
CRP is elevated in many inflammatory conditions. 6
Perimenarchal girls should have a pregnancy test as
part of their diagnostic and preoperative work up.
Scoring systems, such as the Alvarado score
(Table 1), have high sensitivity but low specificity. 7
Based on a meta-analysis, an Alvarado score of 5 or
less has a 99% sensitivity for ruling out appendicitis
and a score of 7 or more has an 82% sensitivity of
TABLE 1 Alvarado Score.
Findings Points
Signs Right lower quadrant tenderness +2
Elevated temperature (N 37.3°C) +1
Rebound tenderness +1
Symptoms Migration of pain to the right lower quadrant +1
Anorexia +1
Nausea or vomiting +1
Laboratory Leukocytosis N 10 000 +2
values Leukocyte left shift +1
probable appendicitis. 8 But not every child with
appendicitis “fits the mold” precisely.
IMAGING
Although much information can be gleaned from
the history, physical examination, and laboratory
results, imaging is an important component of the
diagnostic pathway in pediatric patients (Figure 2).
To minimize radiation exposure and cost, US is
recommended as the first choice imaging study in
evaluating right lower quadrant pain. 9 Ultrasound
findings consistent with appendicitis include a
noncompressible, blind-ending, tubular structure
in the right lower quadrant, which is greater than
6 mm in diameter and lacks peristalsis. Hyperemia
is also commonly seen in acute appendicitis.
Fecaliths, which appear as hyperechoic foci, might
be present. 10 Adjacent inflammatory changes
(hyperechoic fat and free fluid) are suggestive of
but not specific for acute appendicitis.
Ultrasound is limited as a diagnostic modality by
intraabdominal fat, operator error, and retrocecal
appendix location. But when the results are defin-
itive, US can be as effective as CT. 11 In many
pediatric hospitals, the use of US as the initial
imaging modality is becoming a quality measure in
the evaluation of acute onset right lower quadrant
pain. Computed tomography maintains its role
when results are equivocal, or when the US findings
are inconsistent with the history and physical
examination (Figure 3). Although there are few
long-term studies on the effects of diagnostic
imaging, the first long-term follow-up of pediatric
patients who underwent a CT as a child reported a 1
in 100 000 increased incidence of brain tumors and
leukemia. 12 The risk of ionizing radiation from a
single CT is acceptable risk when compared with the
226 VOL. 15, NO. 3 • CLINICAL EVALUATION OF ACUTE APPENDICITIS / MURPHY AND BERMAN

Figure 2. Abdominal pain evaluation pathway.

risk of an unnecessary operation, but the option of INITIAL MANAGEMENT

observation with serial abdominal examinations
should be considered.
In some centers, MRI is the next step in
evaluation of abdominal pain after an equivocal
US (Figure 4). In one study, MRI had 100%
sensitivity and 96% specificity in diagnosing acute
appendicitis after inconclusive US. 13 The use of
MRI is currently limited by expense, patient age
(the examination requires compliance with remain-
ing still), and equipment/technician availability.
Benefits include more detailed imaging than CT
scan without the need for ionizing radiation, which
avoids unnecessary hospitalization.
A child with abdominal pain suspicious for
appendicitis should be managed in a stepwise
fashion, to facilitate proper timing of imaging
studies and surgical consultation (Figure 2). For the
child whose history and physical examination are
concerning for acute appendicitis, an intravenous (IV)
line should be placed, and initial laboratories including
complete blood count, urinalysis, and β human chori-
onic gonadotropin, if appropriate, should be sent. To
counteract dehydration, a 20 mL/kg bolus of crystal-
loid should be administered. The child should be
reevaluated after completion of the fluid bolus, as this
 CLINICAL EVALUATION OF ACUTE APPENDICITIS / MURPHY AND BERMAN • VOL. 15, NO. 3 227

A B

Figure 3. Computed tomographic abdomen demonstrating acute, nonperforated appendicitis. A and B, Computed tomographic abdomen.
Eleven-year-old girl who presents with a 1-day history of right lower quadrant abdominal pain, nausea, and anorexia. Computed tomography
demonstrated a 7-mm fluid-filled appendix with periappendiceal fluid.

often leads to resolution of pain in a dehydrated child
with viral gastroenteritis. If the examination is still
concerning for acute appendicitis, then, right lower
quadrant US should be obtained. For a young boy
with a very convincing examination, it might be
appropriate to request a surgical evaluation before
imaging is obtained. For a perimenarchal girl,
ovarian or pelvic pathology should be considered,
and transabdominal pelvic US should be obtained at
the same time.
If the US is positive for appendicitis or if the US
is negative or equivocal but the examination
continues to be concerning for appendicitis, then,
surgical consultation should be requested. Discussion
between the emergency medicine and surgery teams
should direct next steps, which may include observa-
tion with serial abdominal examinations, axial imag-
ing, or surgical intervention.
TIMING OF SURGERY
Appendicitis is an urgent indication for surgery,
but it is not an emergent one. Performing
appendectomy within 24 hours of presentation does
not significantly increase length of hospitalization or
rate of complications compared with more immediate

A B

Figure 4. Magnetic resonance imaging abdomen demonstrating acute, nonperforated appendicitis. A and B, Magnetic resonance imaging
abdomen. Eleven-year-old boy with a 14-hour history of right lower quadrant abdominal pain. Magnetic resonance imaging demonstrated an
8-mm appendix with periappendiceal fluid.
228 VOL. 15, NO. 3 • CLINICAL EVALUATION OF ACUTE APPENDICITIS / MURPHY AND BERMAN

A B

Figure 5. Computed tomographic abdomen demonstrating perforated appendicitis with large abscess. A and B, Computed tomographic
abdomen. Three-year-old girl with a 5-day-history of abdominal pain. Computed tomographic demonstrated perforated appendicitis with a
9-mm appendicolith and a 6.4 × 8.2 cm abscess with fluid and air. B, Computed tomographic–guided drain placement in abscess cavity.

intervention. 14 Once the diagnosis has been con- MANAGEMENT OF

firmed, antibiotics should be administered, and fluid
resuscitation should be ongoing. For those patients
undergoing appendectomy, the timing of surgery is
usually within 12 to 24 hours of hospitalization but
not necessarily immediately at the time of admission.
CASE 2
A 3-year-old boy presented to the emergency
department with a 6-day history of abdominal pain.
He had presented to his primary care provider’s
office 3 days before and was diagnosed with
streptococcal pharyngitis and started on amoxicillin.
He continued to have fever, nausea and vomiting,
and abdominal pain and was seen in his local
emergency department. The WBC count was 13.2
K/μL. A CT scan of his abdomen demonstrated a 2.1 ×
4.7 × 8.7 cm abscess (Figure 5), and he was
transferred the children’s hospital for further inter-
vention. He was evaluated by interventional radiol-
ogy, and a CT-guided drain was placed in the abscess
cavity. The patient completed a 7-day course of IV
antibiotics and was discharged on hospital day 11 on
a regular diet. He returned with fevers and pelvic
discomfort approximately 3 weeks after discharge,
and CT of the abdomen demonstrated residual
abscess, which was too small to drain. He was
admitted for an additional 7-day course of antibiotics
(3 days of IV antibiotics and 4 days of oral
antibiotics). The patient returned for interval appen-
dectomy 8 weeks after his initial admission and was
discharged in good condition on postoperative day 1.
COMPLICATED APPENDICITIS
Complicated appendicitis is defined as appendicitis
with perforation that results in abscess or phlegmon.
Typically, the child with complicated appendicitis
has difficulty communicating or is less likely to
complain of pain. This might be due to young age,
developmental delay, or autism. Perforated appen-
dicitis also occurs in school-aged children but is less
common in adults (8.8% of children with appendi-
citis present with complicated appendicitis vs 4.8%
of adults). 15 Risk of perforation is also higher among
Asian and Black children compared with White
children as well as children without health insur-
ance and those with public insurance. 16
Perforation may be suspected from history and
physical examination and confirmed by preoperative
imaging but may not be identified until the time of
surgery. When the diagnosis is made upon initial
presentation, it can be managed with initial surgery
(operative management) or with antibiotics followed
by interval appendectomy 6 to 8 weeks after initial
presentation (initial nonoperative management). A
randomized controlled trial showed that there were
no significant differences in length of stay, recurrent
abscess rate, or total charges with operative com-
pared with initial nonoperative management. 17
Children with known complicated appendicitis
should be fluid resuscitated and started on IV
antibiotics. Once they are well hydrated, treatment
decisions can be made. Options include immediate
surgery or a course of antibiotics followed by
 CLINICAL EVALUATION OF ACUTE APPENDICITIS / MURPHY AND BERMAN • VOL. 15, NO. 3 229
interval appendectomy. If initial nonoperative man-
agement is chosen, serial abdominal examinations
should be performed after antibiotics are started. If
there is a well-formed abscess, then it should be
drained if possible. In order for nonoperative
management to be successful, abdominal pain
should subside, fevers should resolve, and the
patient should tolerate a regular diet. There is a
risk of failing nonoperative management even after
initial successful treatment. Failure rates of nonop-
erative management have been reported between
7% and 26%. 18 Risk factors for failure of nonoper-
ative management include presentation with tachy-
cardia, generalized abdominal tenderness, and
abscess smaller than 50 mm. 19 Caregivers should
be educated about signs and symptoms of recurrent
appendicitis in the interval period.
CHOICE AND DURATION OF
ANTIBIOTIC THERAPY
The infectious pathogens of appendicitis are most
often gut bacteria, including enterobacteriacae and
anaerobes, and antibiotics should be directed at
these bacteria. The institutional antibiogram should
be followed, as there are regional differences in
formularies and drug resistance. The child
with nonperforated appendicitis should receive
preoperative antibiotics with enteric coverage
based on institutional recommendations but does
not require postoperative antibiotics. American
Pediatric Surgery Association guidelines recom-
mend that antibiotic duration in perforated
appendicitis be based on clinical criteria for the
child who undergoes nonoperative management and
7 days for the child who undergoes surgical repair. 20
If IV antibiotics are discontinued before the 7-day
mark, the course should be completed with oral
antibiotics. 19 Coverage should initially be broad
spectrum and can then be tailored according to
speciation and susceptibility.
SUMMARY
The lifetime risk of appendicitis is approximately
7%. 21 Implementation of clinical practice guidelines
and care pathways have resulted in shorter lengths of
stay, decreased use of CT scans, and lower rates of
negative appendectomy and missed appendicitis. 22-24
Patients with acute abdominal pain suspicious for
appendicitis should be managed in a stepwise fashion
to facilitate proper timing of imaging studies and
surgical consultation (Figure 2). Key steps in the
management of abdominal pain include early resusci-
tation, appropriate laboratory and imaging testing,
serial examinations, and early consultation of the
surgical team in suspicious cases.
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