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My tummy! Appendicitis
Case presentation
A 10-year-old male presents with 2 days of initially intermittent, now constant, abdominal pain. He states that the pain started on the right side of his abdomen and was crampy in quality, although now has become more sharp. The pain has now localized to the right lower quadrant, although he complains of radiation to the umbilicus and the right upper quadrant. He has not had documented fever but his mother states he has “felt warm” and has reported nausea, but no vomiting, diarrhea, dysuria, or back pain. There is no history of trauma.
His examination reveals a somewhat uncomfortable-appearing child with a temperature of 100.1 degrees Fahrenheit, a heart rate of 105 beats per minute, respiratory rate of 18 breaths per minute, and blood pressure of 100/65 mm Hg. He has tenderness to the right lower quadrant and periumbilical areas, with mild voluntary guarding and rebound to the right lower quadrant. He has no hepatosplenomegaly. He has no scrotal or testicular tenderness or edema. You ask him to ambulate, which he does with some discomfort on the right side. Laboratory evaluation shows a white blood cell count (WBC) of 10 Thou/cc mm with 75% neutrophils and 20% lymphocytes. His urinalysis is normal, except for a specific gravity of >1.030.
Imaging considerations
While the diagnosis of appendicitis is ultimately made by a surgeon in the operative suite, imaging plays an important role in determining which patients may require operative intervention. However, equally important is which patients do not require imaging to make the diagnosis of appendicitis. This is based on clinical suspicion, including specific history and physical examination findings. The decision whether to ultimately obtain imaging may be institution dependent and may be influenced by such factors as availability of pediatric surgical consultation and imaging resources. Even in dedicated pediatric emergency departments, there is variation in initial imaging choice, which is influenced by variation in hospital resources.
There are well-validated appendicitis scoring systems that can be used to determine the probability of appendicitis in the pediatric patient, such as the Pediatric Appendicitis Score. There are also recently proposed scoring systems that have utilized new biomarkers in addition to traditional laboratory testing to assist the clinician in determining which patents are at low risk for appendicitis. Patients with a score suggestive of appendicitis may not need imaging; evaluation by a surgeon prior to imaging in these cases may be appropriate.
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