Navigating Pediatric Appendicitis

Date: November 13, 2024 Reference: Lee WH, et al. Study of Pediatric Appendicitis Scores and Management Strategies: A Prospective Observational Feasibility Study. Academic Emergency Medicine. Dec 2024 Guest Skeptic: Dr. Dennis Ren is a pediatric emergency medicine physician at Children’s National Hospital in Washington, DC. He’s also the host of SGEMPeds. Case: A 10-year-old boy presents to the community emergency department (ED) with abdominal pain. It started last night but the pain seemed to worsen this morning. He tells you that it hurts right around his belly button. On examination, he looks uncomfortable but lets you examine his stomach. He winces a little as you press around his belly button and right lower quadrant but is not guarding. He has not had any fevers. His mother asks you, “I had something like this happen to me when I was a child. By the time they figured it out, the doctors told me that my appendix had almost burst! Do you think this could be appendicitis?” Background: Pediatric appendicitis is the most common surgical emergency in children, accounting for a significant proportion of ED visits. Appendicitis occurs when the appendix becomes inflamed, often because of a blockage, leading to infection and potentially life-threatening complications such as perforation. Although the condition is more common in children between the ages of 10 and 20, it can present at any age, making accurate diagnosis in younger populations especially challenging [1]. The clinical presentation of pediatric appendicitis can vary widely. Classical symptoms include right lower quadrant abdominal pain, fever, and vomiting, but these can be absent or altered in younger children, making clinical diagnosis difficult. Furthermore, the differential diagnosis is broad, including conditions such as gastroenteritis, urinary tract infections, and other causes of abdominal pain like constipation. In one study, almost half of these pediatric patients (45%) with abdominal pain were discharged home with “non-specific abdominal pain” [2].   Traditionally, diagnosis relies on a good history, followed by a directed physical examination and appropriate use of diagnostic tests (lab and imaging). Ultrasound is commonly used due to its non-invasive nature, while computed tomography (CT) scans, although more definitive, are often avoided in children due to radiation concerns [3].  Some centers are using rapid MRI clinical diagnostic pathways in suspected pediatric appendicitis​ [4,5]. Outcomes of appendicitis largely depend on early recognition and treatment. If left untreated, the appendix may rupture, leading to peritonitis, abscess formation, or sepsis, which significantly increases morbidity. On the other hand, early surgical intervention, typically via laparoscopic appendectomy, results in low complication rates and rapid recovery for most pediatric patients​.  Clinical prediction scores (CPS) exist to help diagnose appendicitis in children. They often consider aspects of the history, physical exam and laboratory values. However, these CPSs are not universally used or validated. Three of these CPSs are the Alvarado score [6], Pediatric Appendicitis Score (PAS) [7], and pediatric Appendicitis Risk Calculator for pediatric EDs (pARC-ED) [8].  We also don’t know how they compare to our clinical gestalt. I remember a case I saw as a resident of a young girl who was sent to the ED for belly pain and to be evaluated for appendicitis. Her exam was unremarkable. She didn’t have a fever. She didn’t look sick. I pressed all over her stomach. I had her jump in the air. I looked for the Rosving’s and Psoas's sign. Everything was negative. Her caretaker also told me that her belly pain was like when she had constipation in the past.  It was my attending, whose Spidey senses were tingling, ordered an ultrasound...ruptured appendix. Clinical Question: Can pediatric appendicitis clinical prediction scores accurately diagnos...