Acute Appendicitis in Children: Lecture from Paediatric Surgery Department of Volgograd State Medical University

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

2. POSITIONS OF APPENDIX POSITIONS OF APPENDIX

3. PROFFERED APPENDICEAL ACTIVITIES FUNCRIONS : PROFFERED APPENDICEAL ACTIVITIES FUNCRIONS : lymphatic, lymphatic, exocrine, exocrine, endocrine, endocrine, neuromuscular. 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. 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: Sex: The male-to-female ratio is approximately 2:1. The male-to-female ratio is approximately 2:1.

6. RISK OF DEVELOPING APPENDICITIS WITH AGE RISK OF DEVELOPING APPENDICITIS WITH AGE

7. Age : Age : The mean age in the pediatric population is 6-10 years. 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. 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%. Younger children have a higher rate of perforation, with reported rates of 50- 85%.

9. P erforated appendicitis P erforated appendicitis

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

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

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

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

14. History: 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). 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. Vomiting, RLQ pain, tenderness, and guarding are significantly (all P less than 0.001) associated with appendicitis.

15. History : History : The initial symptom is poorly defined periumbilical pain, often associated with anorexia. 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. 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 appendicitis, nausea and vomiting develop shortly after onset of pain. In most cases of appendicitis, abdominal pain precedes vomiting. In most cases of appendicitis, abdominal pain precedes vomiting.

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

17. History : History : Most children with appendicitis either are afebrile or have a low-grade fever. 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. 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. Vomiting and fever are more frequent in children with appendicitis than in children with other causes of abdominal pain.

18. History : History : A careful family history should be obtained for every child in whom acute appendicitis is suspected. 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. 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. 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 : 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. 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 >6.75 X 103/ m L (6 points). 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 >6.75 X 103/ m L (6 points). A score < 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. A score < 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 : 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. 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 : 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. 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: 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. 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: Physical: Observation of the child's interaction and gait prior to the examination can be extremely helpful. Observation of the child's interaction and gait prior to the examination can be extremely helpful.

24. Physical: Physical: A child with appendicitis typically prefers to lie still due to peritoneal irritation. 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. 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. 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. 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 Rovsing sign is pain in the RLQ in response to left- sided palpation and strongly suggests peritoneal irritation

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

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

28. Physical: 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. 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 rectal examination

30. Causes: 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. 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. Blunt abdominal trauma has been identified as a cause for appendicitis.

31. DIFFERENTIAL : DIFFERENTIAL : Pancreatitis Pediatrics, Diabetic Ketoacidosis Pediatrics, Gastroenteritis Ovarian Cysts Pediatrics, Henoch-Schnlein 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: Other Problems to be Considered: Lymphoma Leukemia Neurogenic appendicopathy Paratubal cysts Intentional injury Sexual abuse Typhilitis Lymphoma Leukemia Neurogenic appendicopathy Paratubal cysts Intentional injury Sexual abuse Typhilitis

33. Prehospital Care: 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. 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. 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 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: 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: 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 Diagnosis not consistent with appendicitis This group includes patients whose history and physical examination are not consistent with appendicitis or any significant abdominal process. 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. Importantly, a complete physical examination, including rectal palpation and urinalysis, should be completed before discharge from the ED.

35. Classic history for appendicitis 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 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 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 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 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. 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. 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. If uncertainty persists after a period of observation, surgical consultation should be obtained. Ultrasonography may be useful when the diagnosis is equivocal. Ultrasonography may be useful when the diagnosis is equivocal.

38. Appendectomy is the definitive treatment for appendicitis. 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. 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. 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. 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 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, 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: Further Inpatient Care: Laparoscopic appendectomy seems to be a safe alternative for the treatment of complicated appendicitis in children. 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. 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. 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. 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. Laparoscopy can be diagnostic for alternative diagnosis in the adolescent female.

41. LAPAROSCOPIC APPENDECTOMY LAPAROSCOPIC APPENDECTOMY

42. LAPAROSCOPIC APPENDECTOMY 2 LAPAROSCOPIC APPENDECTOMY 2

44. Medical Pitfalls: 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. 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 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. 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 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. 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.