Appendicitis Paediatric at CUH



Background

Abdominal pain is a common reason for presenting to the ED. Most children with abdominal pain have mild self-limiting illness such as a viral syndrome, constipation or gastroenteritis. Appendicitis is the most common surgical emergency in children. Clinical prediction rules can safely risk stratify patients thus allowing a tailored approach leading to more efficient utilisation of healthcare resources.


Key Points

  • This clinical pathway does not replace sound clinical judgement.
  • Although less common, younger children, in particular under the age of 5 years, often don't develop classic signs of appendicitis and may present with generalised abdominal pain, vomiting and abdominal distension.
  • Rovsing's, obturator and psoas signs (more on appendicitis page) have poor sensitivity but relatively high specificity (>85%) for appendicitis.
  • WCC is normal in 10%. CRP has lower sensitivity, particularly in the first 24 hours of pain.
  • Further investigations; blood tests and ultrasounds are often not indicated if your clinical suspicion for appendicitis is low. Many children can be discharged with good clinical advice and the abdominal pain handout without the need for further investigations.
  • Consider the differential diagnosis for abdominal pain. If after considering these differentials, appendicitis remains the most likely serious diagnosis then proceed to the pathway below.

Algorithm CUH


Differential Dx

Common & time critical causes of abdominal pain by age
Neonates Infants & Children Adolescents

Hirschprung enterocolitis

Incarcerated hernia

Intussusception

Necrotising enterocolitis

Volvulus

Abdominal trauma

Appendicitis

Constipation

Gastroenteritis

Incarcerated hernia

Intussusception

Meckel's diverticulum

Mesenteric adenitis

Ovarian torsion

Pyloric stenosis

Testicular torsion

Volvulus

Appendicitis

Abdominal trauma

Cholecystitis

Cholelithiasis

Constipation

Ectopic pregnancy

Gastroenteritis

Inflammatory bowel disease

Ovarian cyst – torsion/rupture

Pancreatitis

Pelvic Inflammatory Disease

Renal calculi

Testicular torsion



CUH Guideline metrics

  • Time to US
  • Rate of diagnostic U/S – 1°/2° signs
  • US / CT / MRI utilisation rates
  • Time to blood results
  • Time to first analgesic
  • Time to antibiotics
  • Time to theatre
  • ED and Hospital Length of Stay
  • Negative appendicectomy rate
  • Perforation rates
  • Representation to ED

Content by Dr Rory O'Brien, Dr Sershin Moodley, Dr Íomhar O' Sullivan. Last review Dr ÍOS 31/08/22.