Appendicitis Pediatric - Quick Consult
Last Updated / Reviewed: June 2022

Key History
Key Physical Exam
Differential Diagnosis
Diagnostic Testing
Clinical Risk and Safety Pearls

Key History

  • Most frequent in second decade of life.
  • Neonates: abdominal distention and vomiting, irritability and lethargy.
  • Preschool (age 2 to 5 years): Vomiting, abdominal pain; vomiting precedes the pain; fever, anorexia.
  • School age (6 to 12 years): Abdominal pain and vomiting; typical migration of pain from periumbilical to RLQ may not occur; fever, anorexia and pain with movement common; diarrhea, constipation and dysuria may be present.
  • Adolescents (13 years and older): Similar to adults; anorexia, RLQ pain and vomiting are common; pain typically occurs before vomiting.
Back To Top

Key Physical Exam

  • Neonates: Abdominal distention, hypothermia, hypotension and respiratory distress; palpable abdominal mass.
  • Infants (less than two years): Diffuse abdominal tenderness and fever secondary to rupture; localized RLQ pain occurs in less than 50% of patients.
  • Preschool (2 to 5 years): RLQ tenderness and fever.
  • School age (6 to 12 years): RLQ tenderness and fever; rebound tenderness and involuntary guarding may be seen with perforation.
  • Children with appendicitis prefer to be still.
  • Splinting may be seen secondary to peritoneal inflammation.
  • Generalized tenderness occurs in almost all cases.
  • McBurney's point tenderness (point is 1/3 of the distance on a line starting from the anterior superior iliac crest to the umbilicus) occurs in one-third of cases.
  • Rebound may be present and suggests perforation; however, many surgeons feel this test is unnecessary, as it may be overly sensitive and it causes pain to the child. Surgeons also feel a rectal exam is not always necessary, but may be useful in equivocal cases.
  • Classic appendicitis physical signs such as Rovsing’s, Obturator and Iliopsoas have been shown to be inaccurate in children and may be difficult to elicit.
Back To Top

Differential Diagnosis

Gastrointestinal Genitourinary Other
  • Appendiceal neoplasm
  • Appendicitis
  • Bowel obstruction
  • Cholecystitis
  • Colic
  • Constipation
  • Crohn's disease
  • Diverticulitis
  • Gastroenteritis
  • GERD
  • GI Bleed
  • Hepatitis
  • Hypertrophic pyloric stenosis
  • Inguinal hernia
  • Intestinal malrotation
  • Intestinal Obstruction
  • Intussusception
  • Irritable bowel syndrome
  • Malrotation
  • Meckel’s diverticulitis
  • Mesenteric adenitis
  • Mesenteric ischemia
  • Necrotizing Enterocolitis
  • Omental torsion
  • Pancreatitis
  • Peptic ulcer disease
  • Peritonitis
  • Primary peritonitis
  • Small bowel obstruction
  • Typhlitis
  • Volvulus
  • Diabetes ketoacidosis
  • Hemolytic uremic syndromes
  • Henoch schönlein purpura
  • Herpes zoster
  • Pneumonia
  • Sickle Cell Crisis
  • Streptococcal pharyngiti
Gynecological
  • Dysmenorrhea
  • Ectopic pregnancy
  • Endometriosis
  • Menorrhagia
  • Ovarian torsion
  • PID
  • Ruptured cyst (mittelschmerz)
  • Tubal ovarian abscess
  • Twisted ovarian cyst

Back To Top

Diagnostic Testing

Text / literature information and recommendations include:

  1. Labs:
    • WBC count - May be elevated or normal; a higher white count is associated with perforation
    • Differential with calculation of the absolute neutrophil count
    • C-reactive protein (CRP)
    • Urinalysis may show hematuria or pyuria-found in up to 1/3 of patients with appendicitis
    • B-hCG mandatory to rule out an ectopic pregnancy in females of childbearing age
  2. Imaging - Obtain early surgical consultation before imaging in straightforward cases of suspected appendicitis in adults. Imaging is not universally necessary but may be of benefit in certain populations.
    • Graded compression ultrasound. Ultrasound is the initial imaging modality of choice in children. The study by Benabbas et al. found that a positive ED point-of-care ultrasound performed by expert, trained operators is diagnostic. They also concluded that a negative ED point-of-care ultrasound is not sufficient to rule out acute appendicitis without the use of CT or MRI.
    • Noncontrast CT. Unenhanced, noncontrast abdominopelvic CT should be considered an acceptable imaging modality in the workup of acute appendicitis. There is controversy over the use of IV and oral contrast. Many centers continue to use one or both. CT demonstrates higher diagnostic accuracy than ultrasound or MRI. The disadvantage is the exposure to ionizing radiation.
    • MRI. MRI may be considered as another reliable imaging technology in the evaluation of acute appendicitis in children.

Back To Top

Clinical Risk and Safety Pearls

  • Pain is usually present before the occurrence of nausea and vomiting, unlike gastroenteritis where nausea and vomiting usually occur first.
  • Serial evaluations over several hours may improve diagnostic accuracy in patients with an atypical presentation.
  • The presence of appendicitis is not always apparent on the initial visit. Evaluate and re-evaluate. Document carefully. Demonstrate high-quality care and that the diagnosis was simply not apparent during your evaluation.
  • The urinalysis may show hematuria or pyuria, which is present in up to 1/3 of patients with appendicitis.
  • Order a b-hCG to rule out an ectopic pregnancy in females of childbearing age.
  • Early in the presentation the abdominal exam may be unremarkable.
  • Appendicitis presents most frequently in the second decade of life. Fewer than 5% of patients diagnosed with appendicitis are age 5 or less.
  • Localized RLQ pain develops more often in preschool age children and older.

Back To Top

  1. Andersen, B, Kallehave, F, Andersen, H. Antibiotics versus placebo for prevention of postoperative infection after appendectomy. Cochrane Database Syst Rev. 2005; :CD001439.
  2. Bates MF, Khander A, Steigman SA, Tracy TF Jr, Luks FI. Use of white blood cell count and negative appendectomy rate.Pediatrics. 2014;133(1):e39-e44.
  3. Benabbas R, Hanna M, Shah J, Sinert R. Diagnostic accuracy of history, physical examination, laboratory tests, and point-of-care ultrasound for pediatric acute appendicitis in the emergency department: A systematic review and meta-analysis. Acad Emerg Med. 2017;24(5):523-551.
  4. Bonadio W, Peloquin P, Brazg J, et al. Appendicitis in preschool aged children: Regression analysis of factors associated with perforation outcome. J Pediatr Surg. 2015;50(9):1569-1573.
  5. Dai L, Shuai J. Laparoscopic versus open appendectomy in adults and children: A meta-analysis of randomized controlled trials. United European Gastroenterol J. 2017;5(4):542-553.
  6. Ebell MH, Shinholser J. What are the most clinically useful cutoffs for the Alvarado and Pediatric Appendicitis Scores? A systematic review. Ann Emerg Med. 2014;64(4):365-372.
  7. Expert Panel on Pediatric Imaging; Koberlein GC, Trout AT, Rigsby CK, et al. ACR Appropriateness Criteria®: Suspected Appendicitis-Child. J Am Coll Radiol. 2019;16(5S):S252-S263.
  8. Goldin, AB, Sawin, RS, Garrison, MM, et al. Aminoglycoside-based triple-antibiotic therapy versus monotherapy for children with ruptured appendicitis. Pediatrics. 2007; 119:905.
  9. Gorter RR, Eker HH, Gorder-Starn MA, et al. Diagnosis and management of acute appendicitis. EAES consensus development conference 2015. Surg Endosc. 2016;30(11):4668-4690.
  10. Henry, MC, Walker, A, Silverman, BL, et al. Risk factors for the development of abdominal abscess following operation for perforated appendicitis in children: a multi-center case-control study. Arch Surg. 2007; 142:236.
  11. Melnick ER, Melnick JR, Nelson BP. Pelvic ultrasound in acute appendicitis. J Emerg Med. 38: 240, 2010. [PMID: 18571366]
  12. Muehlstedt, SG, Pham, TQ, Schmeling, DJ. The management of pediatric appendicitis: a survey of North American Pediatric Surgeons. J Pediatr Surg. 2004; 39:875.
  13. Nadler, EP, Reblock, KK, Vaughan, KG, et al. Predictors of outcome for children with perforated appendicitis initially treated with non-operative management. Surg Infect (Larchmt). 2004; 5:3.
  14. Phillips, S, Walton, JM, Chin, I, et al. Ten-year experience with pediatric laparoscopic appendectomy--are we getting better? J Pediatr Surg. 2005; 40:842.
  15. Pogorelić Z, Rak S, Mrklić I, Jurić I. Prospective validation of Alvarado score and Pediatric Appendicitis Score for the diagnosis of acute appendicitis in children. Pediatr Emerg Care. 2015;31(3):164-168.
  16. Rosendahl K, Aukland SM, Fosse K. Imaging strategies in children with suspected appendicitis. Eur Radiol. 14: L138, 2004. [PMID: 14752576]
  17. Sartelli M, Baiocchi GL, Di Saverio S. Prospective Observational Study on acute Appendicitis Worldwide (POSAW). World J Emerg Surg. 2018;13:19.
  18. Sartelli M, Viale P, Catena F, et al. 2013 WSES guidelines for management of intra-abdominal infections. World J Emerg Surg. 2013;8(1):3.
  19. Weber, TR, Keller, MA, Bower, RJ, et al. Is delayed operative treatment worth the trouble with perforated appendicitis is children? Am J Surg. 2003; 186:685.

This is intended solely as reference material and is not a recommendation for any specific patient. The practitioner must rely upon his or her own professional judgment and medical decision-making to determine whether it is relevant in a particular case. Materials are derived from medical and nursing texts, medical literature and national guidelines and should not be considered complete or authoritative. Users must rely on specific patient presentation, experience and judgment when utilizing any of the information contained herein relative to an actual patient.
© 2008 - 2024 The Sullivan Group. All rights to TSG RSQ® Resources are reserved. Unauthorized copying or dissemination is prohibited. U.S. Patent No. 7,197,492