Appendicitis

A diagnosis of appendicitis should be considered in any pediatric patient presenting with acute abdominal pain. Acute appendicitis often presents with a constellation of signs and symptoms, including fever, anorexia, nausea, vomiting, tenesmus, migratory RLQ abdominal pain, abdominal

Table 38-1 Common Pathogens and Recommended Therapy for Acute Diarrhea

Pathogen

Therapy (Adult Doses)

Campylobacter jejuni

Azithromycin, 500 mg qd for 3 days or Ciprofloxacin,* 500 mg bid for 7 days

Clostridium difficile

Metronidazole, 500 mg tid, or 250 mg qid, for 10 14 days or Vancomycin, 125 mg qid for 10-14 days

Entamoeba histolytica

Metronidazole, 500-750 mg tid for 10 days or Tinidazole, 2 g qd for 3 days followed by Paromomycin, 500 mg orally tid for 7 days or lodoquinol, 650 mg tid for 20 days

Escherichia coli 0157:H7

No treatment with antimicrobials or antimotility drugs

E. coli (toxigenic)

Azithromycin, 1 g in 1 dose or Rifaximin, 200 mg tid for 3 days or Levofloxacin,* 500 mg for 1 dose

Giardia lamblia

Tinidazole, 2 g in 1 dose or Nitazoxanide, 500 mg bid for 3 days or Metronidazole, 500-750 mg tid for 5 days

Salmonella spp. (non-typhi)t

Ciprofloxacin, 500 mg bid for 5-7 days or Azithromycin, 1 g for 1 day, then 500 mg qd for 6 days

Shigella spp.

Ciprofloxacin, 500 mg bid for 5-7 days or Levofloxacin, 500 mg qd for 3 days or TMP-SMX-DS, 1 tablet bid for 3 days or Azithromycin, 500 mg for 1 dose, then 250 mg qd for 4 days

Staphylococcus aureus (food poisoning)

No treatment with antimicrobials or antimotility drugs

Vibrio cholerae

Ciprofloxacin, 1 g in 1 dose, plus aggressive fluid hydration

Vibrio parahaemolyticus

No treatment with antimicrobials or antimotility drugs

Yersinia enterocolitica

No treatment unless severe; if severe: Doxycycline, 100 mg IV bid, and

Tobramycin or gentamicin, 5 mg/kg/day qd, or TMP-SMX and fluoroquinolones as alternatives

Modified from Gilbert DN, Moellering RC, Eliopoulos GM, et al. The Sanford Guide to Antimicrobial Therapy, 39th ed. Vermont, Antimicrobial Therapy, 2009. *Avoid fluoroquinolones in pediatric patients and pregnant women.

tAntimicrobial therapy not indicated in asymptomatic patients or those with mild illness. Treatment advised in patients less than 1 year old or greater than 50 years old, if immunocompromised, or if patient has a vascular graft or prosthetic joints.

TMP-SMX, Trimethoprim-sulfamethoxazole; DS, double strength; IV, intravenously; qd, once daily; bid, twice daily; tid, three times daily; qid, four times daily.

tenderness and guarding, and signs of peritoneal irritation. Classically, hours after onset, the pain migrates to McBurney's point, defined as the point two-thirds the distance from the umbilicus along a straight line toward the anterosuperior iliac spine of the pelvis. Rovsing's sign (referred tenderness from LLQ to RLQ during palpation), psoas sign (pain elicited by extending hip posteriorly with patient lying prone), and obturator sign (pain elicited by abducting right hip with patient lying supine) are often conducted but are of little diagnostic value. No sign or combination of signs has accurately predicted acute appendicitis in children (Cincinnati Children's Hospital [CCH], 2002).

While none has proved adequately predictive of acute appendicitis in the pediatric population, laboratory studies are typically performed in the emergency department because other diagnoses may need to be excluded. A series of studies discovered an elevated white blood cell (WBC) count in 87% to 92% of patients with acute appendicitis, although 8% to 13% of patients with appendicitis had a normal WBC count (CCH, 2002). The abdominal examination is particularly unreliable in women of reproductive age, so pelvic exam, urinalysis, and urine pregnancy test represent a reasonable clinical strategy to exclude genitourinary pathology.

Diagnostic imaging is not routinely recommended in patients with a high or a low probability of appendicitis, because it can alter management strategies and has not proved cost-effective; imaging is most helpful when the clinical assessment is equivocal. Controversy exists over the superiority of ultrasound versus computed tomography (CT) in accurately diagnosing appendicitis, and both tests have a positive predictive value approaching 100%. Although ultrasound may be advantageous in thin patients, CT is preferred in the evaluation of a more obese child (Halter et al., 2004). Typical radiographic findings in the evaluation of acute appendicitis include appendicoliths (Fig. 38-1), dilation of the appendix with adjacent hazy fat (Fig. 38-2), and periappendiceal abscesses (Fig. 38-3). If the abdominal CT does not show evidence of acute appendicitis, the patient may either be admitted for observation or discharged at the discretion of the examiner and parents, with instructions for follow-up if symptoms worsen. Expert opinion states that if there is high suspicion of appendicitis on the basis of history, physical examination, and laboratory studies, the patient should go directly to the operating room for an exploratory laparotomy to evaluate the appendix, without an imaging study.

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