Pediatric emergency medicine trisk 3738 3738

Young children often have nonclassic presentations of appendicitis
Pain and tenderness will vary based on exact location of the appendix
Rapid improvement in pain in a child with high suspicion of appendicitis
may occur at the time of perforation
Diagnostic algorithms should incorporate a clinical risk score and
ultrasound as the first-line imaging modality

Current Evidence
Acute appendicitis is the most common nontraumatic surgical emergency in
children. Anatomic characteristics may influence the incidence and presentation
of appendicitis throughout childhood. Lymphoid hyperplasia within the appendix
is maximal in adolescence and might be related to the peak incidence in this age
group. Generally, obstruction of the appendix (by fecal material, an appendicolith,
or simply lymphoid hyperplasia) is believed to be a key step in the development
of appendicitis. Once obstructed, bacterial overgrowth and invasion into the
mucosal barrier lead to progressive inflammation and dilation. Localized pain and
tenderness develops. Perforation rarely develops before 12 hours of pain but is
common after 72 hours. Perforation can lead to generalized peritonitis or focal
abscesses. Since younger children have a relatively underdeveloped omentum,
they are much more likely to present with diffuse peritonitis.

Goals of Treatment
Early recognition and treatment prior to perforation is ideal. Ultrasound (US)
should be used as the first-line imaging modality in stable patients, with advanced
imaging reserved for children with nondiagnostic US and a persistent clinical
concern for appendicitis. Clinical outcomes for patients with suspected
appendicitis include accurate identification of appendicitis over medical
etiologies of focal abdominal tenderness, limiting the use of computed
tomography among patients with uncomplicated acute appendicitis, minimizing
the number of negative appendectomies, definitive treatment prior to perforation,
and the consideration of serial examinations over advanced imaging for patients

considered low risk for appendicitis.

Clinical Considerations
Clinical Recognition
The peak incidence of appendicitis in children occurs between 9 and 12 years of
age. Although neonatal cases have been reported, appendicitis rarely occurs in