| Print Date: | May 22, 2013, 1:22 pm |
| Title | Acute appendicitis |
| Text | Appendicitis occurs most frequently in the 2nd to 3rd decade of life, less commonly in the extremes of age. Pain is usually the initial presenting complaint and often starts in the peri-umbilical region before migrating to the right lower quadrant with maximal tenders often located at McBurney’s point. This typical sequence is absent in more than 1/3 of older children. Often pain is worse with movement, coughing (cough sign) driving over bump (cat\'s eye sign), or standing on toes and dropping heels to ground (heel drop sign) (Rothrock). Vomiting occurs in the majority of school-aged children and may precede or begin concurrent with pain. Physical exam often reveals an elevated temperature and tenderness to palpation in the right lower quadrant. However, tenderness may involve the entire lower abdomen, or may be diffuse, especially with a perforation. Compared with those with non-perforated appendicitis, children with perforated appendicitis are significantly younger, have a longer duration of symptoms before diagnosis, have more physician visits before correct diagnosis, have higher temperatures, and are more likely to exhibit vomiting, diffuse abdominal tenderness, and peritoneal signs (Rothrock). Perforation generally occurs 36 to 48 hours after the onset of symptoms. Plain abdominal radiographs have been recommended as potentially useful for evaluating children with suspected appendicitis. Radiographic findings believed to be suggestive of appendicitis include rightward scoliosis, soft tissue masses, localized ileus, bowel obstruction, calcified fecolith, and free peritoneal fluid. Of these features, the most specific for appendicitis is a calcified fecolith (appendicolith) found in up to 13% to 22% with appendicitis and in only 1% to 2% of those without (Rothrock). While often recommended, these films rarely altered a patient\'s diagnosis or management. Ultrasonography is appropriate in patients in which the diagnosis is unclear by history and physical examination, especially in pediatric and female patients. A normal appendix must be identified to rule out appendicitis. An inflamed appendix usually measures greater than 6 mm in diameter, is non-compressible and tender with focal compression (Hardin). Numerous other right lower quadrant conditions such as inflammatory bowel disease, cecal diverticulitis, Meckel\'s diverticulum, endometriosis and pelvic inflammatory disease can cause false-positive ultrasonography results (Hardin). Appendiceal CT is more accurate than ultrasound and consists of a focused, helical CT after a Gastrografin-saline enema. It can be performed and interpreted usually within an hour. The accuracy of CT is due in part to its ability to identify a normal appendix better than ultrasound. If appendiceal CT is not available, standard abdominal/pelvic CT with contrast remains useful and may still be more accurate than ultrasound (Hardin). The standard for management of appendicitis remains appendectomy. The procedure may be performed by laparotomy (usually through a small right lower quadrant incision) or laparoscopy. While laparoscopic intervention is advantageous in adults due to decreased postoperative pain, earlier return to normal activity and better cosmetic results, an open appendectomy remains the primary approach to treatment in children due to their smaller size (Rothrock).
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Abstract&list_uids=15155894 |
| References: | Contran, et al. Robbins: Pathologic Basis of Disease, 6th ed. 1999, W.B Saunders Co.
Hardin DM Jr: Acute appendicitis: review and update. American Family Physician. 1-Nov-1999; 60(7): 2027-34 Rothrock SG: Acute appendicitis in children: emergency department diagnosis and management. Annals of Emergency Medicine. 01-Jul-2000; 36(1): 39-51 |
| Contributor | MS-4 USU Teaching File (Uniformed Services University) |
| Author | 2LT Kristin Silvia |
| Peer Reviewer | Veronica J Rooks (Walter Reed Army Medical Center) |
| Record Number | : 4156 |
| Created | 2002-09-16 09:48:49-04 |
| Modified | 2004-08-17 23:47:27-04 |
| Category: | Infection, bacteria |
| Location: | Gastrointestinal |
| Sublocation: | Appendix |
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