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Paediatrics: Acute appendicitis

Acute appendicitis is the commonest abdominal emergency in children, affecting approximately one-sixth of the population.

Acute appendicitis

 

Acute appendicitis is the commonest abdominal emergency in children, affecting approximately one-sixth of the population. Acute appendicitis begins with obstruction of the lumen of the appendix, often by a faeco-lith, and this causes vague central abdominal pain. After about 6–12hr an inflammatory process involves the full thickness of the wall of the appen-dix. After a further 24–36hr the appendix will become gangrenous and perforate. Irritation of the peritoneum results in more severe abdominal pain localized to the right iliac fossa.

   Pain is aggravated by movement.

 

   Child may prefer to lie still with knees flexed.

 

   Mild fever is usual.

 

   Peritoneal irritation results in involuntary spasm in the muscles of the abdominal wall—‘guarding’.

 

Diagnosis

 

The mortality from appendicitis is virtually zero. However, substantial morbidity is incurred by delayed diagnosis. The diagnosis of appendicitis is clinical and laboratory investigations are generally not helpful.

 

   The ‘classical’ symptoms and signs of acute appendicitis are seen in about 60% of cases.

 

   Of all children admitted to hospital with abdominal pain only about 30% will have acute appendicitis. Not all of these cases are obvious at the initial assessment (probably only 50–70%); if there is any doubt, child should be admitted to hospital for observation.

 

   Urinalysis is abnormal in about 1/3 children with acute appendicitis: pyuria and even bacteriuria may be present. The temptation to start antibiotics for a presumptive diagnosis of UTI should be avoided unless there are symptoms of dysuria.

 

   The WCC is normal in 10–20% of children with appendicitis.

 

US: if there is clinical doubt, US is the investigation of choice. The overall accuracy of US in the diagnosis of acute appendicitis is around 90%.

 

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