Appendicitis may present at any age, although most common in adolescents. The incidence varies by country, geographic region, race, sex and season. The appendix is a reservoir for normal intestinal flora and has the highest concentration of gut associated lymphoid tissue (GALT).

• Obstruction of the lumen of appendix by faecolith, parasites,

• lymphoid hyperplasia results increased intraluminal pressure, congestion and finally ischemia.

Appendicular artery a branch of the ileocolic artery is an end artery, and block in its branches leads to gangrene and perforation. Bacteria then spreads into the abdominal cavity, leading to localized infection causing an abscess, or generalized infection in the entire abdominal cavity.

History

• Malaise, nausea, anorexia, vomiting, and low-grade fever.

• Peri-umbilical pain which migrates to the RIF.

• Pelvic appendix would present as diarrhea due to irritation of the rectum.

Examination

• Right lower quadrant tenderness.

• Rebound Tenderness can be assessed in older children.

• Obturator sign is right lower quadrant pain with flexion and internal rotation of the hip.

• Rovsing sign is positive (pain in the right lower quadrant with gentle pressure on the left lower quadrant).

• Psoas Sign is positive in retrocaecal appenditicis. This is pain when the patient is in the left decubitus position and the right leg extended.

• Dunphy’s sign is increased right iliac fossa pain with coughing.

• Limping Gait.

• Guarding/rebound in suprapubic and LIF regions / rigidity signify perforation.

• Abdominal pain of unknown origin in preschool children

- mesenteric lymphadenitis

○ gastroenteritis

○ intussusception

• Adolescent girls

- mittelschmerz

○ ovarian torsion/cyst

○ pelvic inflammatory disease,

○ ectopic pregnancy

○ primary peritonitis

• Rare

- Meckel’s diverticulitis

○ omental torsion

○ testicular torsion

• Pneumonia.

• Henoch-Schonlein purpura and other vasculitis.

• Inflammatory bowel disease.

• Constipation.

• Laboratory investigations (leukocytosis, left shift of neutrophil count & raised CRP/IL-6).

• Low Sodium level correlates with advance disease.

• Plain radiograph not recommended as neither sensitive nor specific.

• Ultrasonography (USG): Graded compression USG showing an enlarged, non-compressible appendix 6 mm or more in diameter. Peri-appendicular edema, free fluid and faecolith are other complimentary findings [Puylaert criteria]. Ultrasound has 80-100% sensitivity and 78-98% specificity, with overall accuracy of 91%. However, this is user dependent and less sensitive in obese children.

• CT abdomen: Higher accuracy in diagnosing appendicitis, however not generally recommended due to radiation exposure.

• MRI has become an interesting alternative to CT scan due to exclusion of ionizing radiation.

• Scoring systems: AIR score has outperformed the Alvarado, Pediatric Appendicitis sco

res (PAS).

• The first Line of treatment in suspected appendicitis is the restoration of homeostasis, which should be initiated during diagnostic workup at the emergency department.

• IV line is established for rehydration (10mls per kilo bolus of 0.9/% saline can be given).

• Adequate pain relief (there is no evidence that early, balanced pain relief delays or obscures the diagnosis).

• Acute non perforated appendicitis: Early appendicectomy – laparoscopic versus open.

• Advantages of laparoscopic appendectomy are a shorter hospital stay, small incision sites, and possibility for diagnostic laparoscopy if appendix is normal.

• Postoperative complications between open and laparoscopic appendectomy are similar (intra-abdominal abscess, stitch abscess, wound infection and small bowel obstruction).

• Insertion of a central line for Antibiotics +/- Parenteral nutrition in those that are slow in recovery to ensure adequate calorie intake.

• Admission for observation in suspected cases; Continuous assessment and IV antibiotics is an essential component.

• Systematic review and meta-analysis show that NOT for non-perforated acute appendicitis in children is safe and successful (defined as resolution of symptoms and discharge from initial hospital stay without appendectomy) in 92% of patients, 16% later undergo appendectomy due to recurrent acute appendicitis or recurrent abdominal pain. The hospital stay is similar in patients treated non-operatively and with appendectomy.

• Risk of failure and recurrent appendicitis higher in presence of appendicolith.

• Seen in about 8-10% of cases, esp. in children with appendicitis presenting later than 3 days.

• Management can be with conservative management with antibiotics or surgery (esp. in early mass formation).

• However, higher risk of complications reported, like difficult dissection of adhesions, small bowel injury, prolonged ileus, and infection.

• Children presenting with diffuse peritonitis need early surgery, however those presenting with defined abscesses/collections can be managed with antibiotics and percutaneous drainage.

• Interval appendicectomy after 6-8 weeks may be offered to children managed conservatively for mass/abscess.

• Culture of the peritoneal fluid is recommended – as it helps to decide on change of antibiotics incase complications like pelvic abscess develops.

• In complicated appendicitis, a peritoneal drain may be left depending on surgical findings and surgical decision.

Negative appendectomy: is where a patient has an appendectomy for suspected appendicitis but is then found not to have appendicitis. This is confirmed when the appendix is examined histologically.

• Recurrent appendicitis is quoted in 10-16% following NOT.

• Higher risk in presence of appendicolith.

• Hence interval procedure should be offered in children with appendicolith, and is optional in others.

• Parents should be counseled. Interval appendicectomy after 8 weeks may be offered to children managed conservatively

Antibiotics guidelines are often decided by institutional protocol.

• Uncomplicated: Single broad-spectrum antibiotic or a combination of second-generation cephalosporin like cefuroxime, with metronidazole.

• Complicated: Second generation cephalosporin, aminoglycoside(gentamicin), Metronidazole until fever settles.

Early 

• Surgical site infection

• Intra-abdominal abscess

• Late

• Adhesive intestinal obstruction

• Infertility due to tubal adhesions in girls after perforated appendicitis with peritonitis.

• Stump appendicitis risk less than 0.15%.

• Normal appendix found on table: look for Meckel’s diverticulum or other pathology like primary peritonitis.

• If all else normal consider appendicectomy.

• Mucocele or mass (carcinoid tumor): follow up histopathology and institute treatment.

The evaluation of a child with suspected appendicitis should focus on a proper diagnosis, using modern diagnostic tools to minimize the risk of misdiagnosis and negative appendectomy. Appendicitis scoring systems may aid the correct diagnosis but have limited value as a single diagnostic tool. Early rehydration, analgesics, and in selected cases, antibiotic treatment for suspected or diagnosed perforation should be prioritized.