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ACUTE APPENDICITIS IN CHILDREN

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The role of race, ethnicity, health insurance, education, access to healthcare, ... Most children with appendicitis either are afebrile or have a low-grade fever. ... – PowerPoint PPT presentation

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Title: ACUTE APPENDICITIS IN CHILDREN


1
ACUTE APPENDICITIS IN CHILDREN
  • LECTURE FROM PAEDIATRIC SURGERY DEPARTAMENT OF
    VOLGOGRAD STATE MEDICAL UNIVERSITY
  • AUTOR O.I. VERBIN, ASSISTENT OF PAEDIATRIC
    SURGERY DEPARTAMENT

2
POSITIONS OF APPENDIX
3
PROFFERED APPENDICEAL ACTIVITIES FUNCRIONS
  • lymphatic,
  • exocrine,
  • endocrine,
  • neuromuscular.

4
  • The role of race, ethnicity, health insurance,
    education, access to healthcare, and economic
    status on the development and treatment of
    appendicitis are widely debated. Cogent arguments
    have been made on both sides for and against the
    significance of each socioeconomic or racial
    condition.

5
Sex
  • The male-to-female ratio is approximately 21.

6
RISK OF DEVELOPING APPENDICITIS WITH AGE
7
Age
  • The mean age in the pediatric population is 6-10
    years.
  • Appendicitis is rare in the neonate, and the
    diagnosis in this age group is typically made
    after perforation.
  • Younger children have a higher rate of
    perforation, with reported rates of 50-85.

8
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9
Perforated appendicitis
10
Mortality/Morbidity
  • At the time of diagnosis, the rate of perforation
    varies from 17-40, with a higher frequency
    occurring in younger age groups.
  • The mortality rate for children with appendicitis
    ranges from 0.1-1.
  • Perforation increases the complication rate.

11
Causes of right iliac fossa mass
  • Appendix mass
  • Crohn's disease
  • Caecal carcinoma
  • Mucocele of the gallbladder
  • Psoas abscess
  • Pelvic kidney
  • Ovarian cyst

12
Causes of right iliac fossa pain
  • Appendicitis
  • Urinary tract infection
  • Non-specific abdominal pain
  • Pelvic inflammatory disease
  • Renal colic
  • Ectopic pregnancy
  • Constipation

13
CLINICAL FEATURES OF APPENDICITIS
  • Central abdominal pain moving to right iliac
    fossa
  • Nausea, vomiting, anorexia
  • Low-grade pyrexia
  • Localised tenderness in right iliac fossa
  • Right iliac fossa peritonism
  • Percussion tenderness is a kinder sign of
    peritonism than rebound
  • Rovsing's sign pain in right iliac fossa on
    palpation of the left iliac fossa

14
History
  • Understanding the typical clinical manifestations
    of appendicitis is important in order to make an
    early and accurate diagnosis prior to
    perforation. The classic history of anorexia and
    periumbilical pain, followed by right lower
    quadrant (RLQ) pain and vomiting, is observed in
    fewer than 60 of patients. The clinician is more
    likely to make the diagnosis by maintaining a
    high degree of suspicion, a broad differential
    diagnosis, and looking for the atypical case
    rather than the classic appendicitis (1-2 d of
    fever, vomiting, right lower quadrant pain,
    anorexia).
  • Vomiting, RLQ pain, tenderness, and guarding are
    significantly (all P less than 0.001) associated
    with appendicitis.

15
History
  • The initial symptom is poorly defined
    periumbilical pain, often associated with
    anorexia.
  • Acute onset of severe pain is typically present
    with acute ischemic conditions, such as volvulus,
    testicular torsion, ovarian torsion, or
    intussusception.
  • In appendicitis, nausea and vomiting develop
    shortly after onset of pain.
  • In most cases of appendicitis, abdominal pain
    precedes vomiting.

16
History
  • After a few hours, the pain shifts to the RLQ due
    to inflammation of the parietal peritoneum.
  • This pain is more intense, continuous, and more
    localized than the initial pain.
  • This shift of pain rarely occurs in other
    abdominal conditions.

17
History
  • Most children with appendicitis either are
    afebrile or have a low-grade fever.
  • High fever is not a common presenting feature
    unless perforation has occurred.
  • Vomiting and fever are more frequent in children
    with appendicitis than in children with other
    causes of abdominal pain.

18
History
  • A careful family history should be obtained for
    every child in whom acute appendicitis is
    suspected.
  • Multiple studies have demonstrated that children
    who have appendicitis are more than likely to
    have a positive family history.
  • To date, not enough evidence exists to support a
    major gene for appendicitis. Nonetheless, a
    positive family history of appendicitis must be
    appreciated and respected when evaluating a child
    with abdominal pain.

19
History
  • Evaluation rules and algorithms have been
    proposed to help the clinician make the correct
    diagnosis and treatment plan. Nothing in
    emergency medicine is guaranteed, but decision
    rules can predict which children are at low risk
    for appendicitis.
  • One such numerically based system is based on a
    6-part scoring system nausea (2 points), history
    of focal RLQ pain (2 points), migration of pain
    (1 point), difficulty walking (1 point), rebound
    tenderness/pain with percussion (2 points), and
    absolute neutrophil count of gt6.75 X 103/mL (6
    points).
  • A score lt 5 had a sensitivity of 96.3 (95
    confidence interval CI, 87.5-99.0), a negative
    predictive value of 95.6 (95 CI, 90.8-99.0),
    and a negative likelihood ratio of 0.102 (95 CI,
    0.026-0.405) in the validation set.

20
History
  • The keys to any evaluation and treatment plan
    that involve equivocal history, physical
    examination findings, and inconclusive supporting
    test results include relieving the patient's pain
    and discomfort early and often, communicating
    with the patient and family about the plans,
    discovering and addressing concerns, repeating
    the examination often, adjusting the differential
    diagnosis, and keeping the patient for
    observation if a firm diagnosis is not made or
    for follow-up.

21
History
  • Algorithms, scoring systems, imaging studies, and
    consultation reports are part of the clinician's
    armamentarium. Always document what actions were
    taken or why actions were not taken in a
    particular way. Let the record reflect the
    thought process and support for the thought
    process with reports such as algorithms and
    scoring systems.

22
Physical
  • Children vary in their ability to cooperate with
    the physical examination. It is important to
    tailor the physical examination with respect to
    the child's age and developmental stage. It is
    important to exclude extra-abdominal causes of
    abdominal pain.

23
Physical
  • Observation of the child's interaction and gait
    prior to the examination can be extremely
    helpful.

24
Physical
  • A child with appendicitis typically prefers to
    lie still due to peritoneal irritation.
  • Observing the child's facial expression during
    palpation of the abdomen can be helpful in
    eliciting the location and intensity of any
    abdominal pain.
  • Localization of the pain depends on the position
    of the appendix.
  • Typically, maximal tenderness can be found at
    McBurney point in the right lower quadrant.
  • Rovsing sign is pain in the RLQ in response to
    left-sided palpation and strongly suggests
    peritoneal irritation

25
Physical
  • The psoas sign is determined by placing the child
    on the left side and hyperextending the right
    leg.

26
Physical
  • The obturator sign is determined by internal
    rotation of the flexed right thigh. Pain on
    movement may be caused by an inflammatory mass
    overlying the psoas muscle.

27
Physical
  • The cough sign (sharp pain in the RLQ after a
    voluntary cough) is suggestive of peritoneal
    irritation.

28
Physical
  • A rectal examination should be performed last and
    may reveal impacted stool, right-sided
    tenderness, or a mass. Be sure to perform a
    rectal examination (inspection, palpation, and
    digital examination) in children who have any
    abdominal tenderness, a history of constipation,
    a history of rectal bleeding, trauma, or
    suspected physical abuse.

29
rectal examination
30
Causes
  • Most causes of appendiceal inflammation,
    infection, and perforation begin with something
    obstructing the appendiceal lumen. Items such as
    stool, barium, food, and parasites can block the
    lumen. Malignant tissue such as that caused by
    carcinoid, leukemia, and lymphoma can cause
    tissue swelling and lumen obstruction.
  • Blunt abdominal trauma has been identified as a
    cause for appendicitis.

31
DIFFERENTIAL
  • Pancreatitis Pediatrics, Diabetic Ketoacidosis
    Pediatrics, Gastroenteritis Ovarian Cysts
    Pediatrics, Henoch-Schönlein Purpura Pediatrics,
    Intussusception Pediatrics, Pneumonia
    Pediatrics, Sickle Cell Disease Pediatrics,
    Urinary Tract Infections and Pyelonephritis
    Pelvic Inflammatory Disease Pregnancy, Ectopic
    Renal Calculi Testicular Torsion

32
Other Problems to be Considered
  • Lymphoma Leukemia Neurogenic appendicopathy Paratu
    bal cysts Intentional injury Sexual
    abuse Typhilitis

33
Prehospital Care
  • Emergency medical service (EMS) personnel are
    well-trained and cognizant of how to assess and
    begin treatment of the febrile, vomiting, child
    with abdominal pain.
  • Intravenous fluid administration, pain
    management, and antiemetic medication should be
    administered based on local EMS protocols.
  • The EMS provider must gather accurate "QRST" data
    including estimated fluid intake and loss, the
    child's weight gain or loss, and home remedies
    and interventions

34
Emergency Department Care
  • One of the difficult challenges in evaluating
    children with abdominal pain is making a timely
    diagnosis prior to appendiceal perforation. In
    the ED, classifying patients with abdominal pain
    into the following 3 categories may be helpful
  • Diagnosis not consistent with appendicitis
  • This group includes patients whose history and
    physical examination are not consistent with
    appendicitis or any significant abdominal
    process.
  • Importantly, a complete physical examination,
    including rectal palpation and urinalysis, should
    be completed before discharge from the ED.

35
Classic history for appendicitis
  • Patients with a classic history for appendicitis
    require prompt surgical consultation but may not
    require emergency surgery. In fact, emergency
    appendectomy (operation within 6 h) in children
    has no advantages over urgent appendectomy
    (operation with 12 h) with respect to gangrene
    and perforation rates, readmissions,
    postoperative complications, hospital stay, or
    hospital charges. This does not mean the
    emergency physician who has made the diagnosis of
    appendicitis will not contact the surgeon right
    away, but the hospital admission and course must
    be discussed with the surgeon, patient, and
    family

36
Antibiotic therapy
  • is an important aspect of the treatment of
    ruptured appendicitis. Antibiotic therapy should
    be directed against gram-negative and anaerobic
    organisms such as Escherichia coli and
    Bacteroides species. The administration of
    antibiotics, nasogastric tubes, intravenous
    lines, urethral catheters, antiemetic medicine,
    antipyretic medicine, and analgesia should
    ideally be part of the ED protocol for managing
    the preoperative child. Proponents of
    preoperative antibiotic recommend that all
    children with appendicitis receive gentamicin and
    clindamycin

37
Unclear diagnosis
  • In these children, the history may be consistent
    with appendicitis, while the examination is not,
    or the examination may be suggestive of
    appendicitis in the face of an unremarkable
    history. In the latter group, obtaining
    laboratory studies and radiographs and
    reevaluating the patient over a few hours to
    determine the need for surgical consultation is
    helpful.
  • Serial examinations of the patient in the ED
    along with results of the studies may help to
    clarify the diagnosis.
  • If uncertainty persists after a period of
    observation, surgical consultation should be
    obtained.
  • Ultrasonography may be useful when the diagnosis
    is equivocal.

38
Appendectomy is the definitive treatment for
appendicitis.
  • Pediatric patients with appendicitis can undergo
    laparoscopic appendectomy (versus open
    appendectomy) without incurring a greater risk
    for complications.
  • Fifteen to 20 of appendectomies are performed in
    cases for which test results are later determined
    to be falsely positive, as appendicitis is
    difficult to diagnose in infants and toddlers.
  • Nontoxic patients with a localized walled-off
    abscess may be candidates for initial medical
    management with antibiotics, followed by an
    elective appendectomy.

39
Preoperative antibiotics
  • are given to children with suspected appendicitis
    and stopped after surgery if no perforation
    exists. Patients presenting with perforated
    appendicitis may be volume depleted and require
    aggressive fluid resuscitation. The combination
    of ampicillin, clindamycin, and gentamicin is
    administered to treat infection from aerobic and
    anaerobic organisms. Alternative regimens include
    ampicillin and sulbactam,

40
Further Inpatient Care
  • Laparoscopic appendectomy seems to be a safe
    alternative for the treatment of complicated
    appendicitis in children.
  • Potential advantages of laparoscopic appendectomy
    include reduced postoperative pain and lower
    wound infection rate.
  • Pediatric laparoscopic patients have fewer wound
    problems and shorter duration of oral pain and
    medication usage.
  • In addition to advantages for the patient, their
    parents returned to work quicker than parents of
    children who had open appendectomy.
  • Laparoscopy can be diagnostic for alternative
    diagnosis in the adolescent female.

41
LAPAROSCOPIC APPENDECTOMY
42
LAPAROSCOPIC APPENDECTOMY 2
43
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44
Medical Pitfalls
  • Performing a complete examination including
    examination of the genitals is important.
    Symptoms and signs of testicular torsion and
    ectopic pregnancy overlap with appendicitis and
    have serious morbidity if not quickly diagnosed.
  • Patients should not be diagnosed with the
    gastroenteritis unless they have nausea,
    vomiting, and diarrhea. Patients with nonspecific
    abdominal complaints should be diagnosed with
    abdominal pain of unknown etiology. Patients
    should be instructed to be reevaluated in 8-12
    hours by their primary care physician or return
    to the ED.
  • Patients with an equivocal examination should be
    kept for observation and followed-up by serial
    abdominal examinations. Avoid treating patients
    with vague abdominal pain with parenteral opiates
    and then discharging them.
  • Misdiagnosed patients were younger and more
    likely to have vomiting before pain onset,
    constipation, diarrhea, dysuria, and signs and
    symptoms of upper respiratory infections.
  • Misdiagnosed patients were more likely to have
    pain duration of more than 2 days, to have a
    temperature of more than 38.3C, and to appear
    lethargic and irritable.

45
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