Appendicitis in Children

Intro & Pathophysiology - Genesis of Gut Grief

• Appendicitis: Acute inflammation of the vermiform appendix.
• Most common non-traumatic pediatric surgical emergency; peak incidence 10-19 years.
• Pathogenesis: Initiated by obstruction of the appendiceal lumen, leading to a cascade.
  • Children: Lymphoid hyperplasia (60-70%, often post-viral URI) is the primary culprit.
  • Other causes: Fecaliths, inspissated stool, parasites (e.g., Ascaris), foreign bodies, rarely tumors.

⭐ Lymphoid follicular hyperplasia in the submucosa is the most frequent cause of luminal obstruction in children, distinguishing it from adult appendicitis where fecaliths are more common (accounting for ~60% of pediatric cases).

Clinical Picture - Tiny Tummy Troubles

• Classic Sequence: Periumbilical pain → migrates to RIF (McBurney's point).
• Associated Symptoms:
  • Anorexia (highly consistent).
  • Nausea & Vomiting (typically after pain onset).
  • Fever (low-grade, ↑ if perforated).
• Key Physical Signs:
  • Localized RIF tenderness, guarding.
  • Rebound tenderness.
  • Rovsing's sign (pain in RIF on LLQ palpation).
  • Psoas/Obturator signs (retrocecal/pelvic appendix).
• Age-Specifics:
  • Infants/Young Children (<5 yrs): Atypical; diffuse pain, irritability, vomiting, diarrhea. Higher perforation risk.

⭐ Younger children (<5 yrs) present atypically, leading to delayed diagnosis and ↑ perforation rates (e.g., 80-100% in neonates).

Diagnostic Drilldown - Spotting the Sneak

• Clinical Scoring Systems:
  • Alvarado Score (📌 MANTRELS): Score > 7 highly indicative.
  • Pediatric Appendicitis Score (PAS): Score > 6 high risk. Key: RLQ tenderness, cough/hop pain, N/V, anorexia, fever >38°C, WBC >10k, PMN >7.5k.
• Imaging Modalities:
  • Ultrasound (USG): Preferred initial imaging.
    • Appendix diameter > 6mm.
    • Non-compressible, aperistaltic.
    • Wall thickening, "target sign".
    • Free fluid, appendicolith.
  • CT Scan: If USG equivocal or suspected complications. Higher accuracy, radiation risk.
  • MRI: Alternative to CT; no radiation.

⭐ The Pediatric Appendicitis Score (PAS) is often preferred over Alvarado in children due to its higher specificity and validation in pediatric populations.

Treatment Tactics - Eviction Notice!

• Appendectomy: Mainstay. Laparoscopic preferred (↓pain, ↓LOS). Open for complex cases.
• Antibiotics (ABX): 📌 "APPendicitis ABX": Pre-op, Post-op.
  • Pre-op: Broad-spectrum (e.g., Cefoxitin, Gentamicin+Metronidazole).
  • Post-op:
    • Non-perforated: Stop within 24 hrs.
    • Perforated/Gangrenous: IV for 3-7 days.
• Non-Operative Management (NOM): For select, stable, uncomplicated cases (antibiotics alone).
• Complicated (Abscess/Phlegmon):
  • Initial: IV ABX, bowel rest, +/- percutaneous drainage (abscess > 3-4 cm).
  • Interval Appendectomy: 6-8 weeks later (controversial).
• Management Flow:

⭐ Interval appendectomy after successful NOM for complicated appendicitis reduces recurrence risk (10-20%) and allows histological diagnosis.

Complications & DDx - Watch Outs!

• Perforation (common, esp. <5 yrs)
• Abscess (pelvic, appendiceal)
• Phlegmon
• Sepsis
• Wound infection
• Late: Adhesive bowel obstruction

High‑Yield Points - ⚡ Biggest Takeaways

• Appendicitis is the most common surgical emergency in children.
• Younger children (<5 years) often have atypical presentations, ↑ risk of perforation.
• Classic symptoms: periumbilical pain migrating to RIF, vomiting, and fever.
• McBurney's point tenderness is a crucial diagnostic sign.
• Pediatric Appendicitis Score (PAS) or Alvarado score aids clinical diagnosis.
• Ultrasound is the preferred initial imaging; CT for equivocal cases.
• Treatment is appendectomy (laparoscopic preferred) and appropriate antibiotics.