Paeds- Appendicitis

Question 1

Where is the typical abdominal pain in appendicitis?

a) LIF
b) RIF
c) Central then localises to RIF
d) RUQ

Answer 1

c) Central then localises to RIF

An SBA format requires the best answer, which would be (c) not (b) The pain starts central/periumbilical then localises to the RIF as the appendix irritates the peritoneum

Question 2

Which option indicates a positive Psoas sign?

a) Pain on flexion of the left thigh with the patient lying supine
b) Pain on hyperextension of the right thigh with the patient lying in either the left or right lateral position
c) Pain on flexion of the right thigh with the patient lying supine
d) Pain on hyperextension of the right thigh with the patient lying in the left lateral position

Answer 2

d) Pain on hyperextension of the right thigh with the patient lying in the left lateral position

Hyperextension not flexion

Right thigh (to irritate the RIF) not left/both

Lying in the left lateral position not supine

Question 3

Vague pain, described as a deep pressure/aching, is an example of:

a) Visceral peritoneum pain
b) Parietal peritoneum pain

Answer 3

a) Visceral peritoneum pain

Progression is from visceral (vague central) to parietal (RIF) pain Parietal pain results from irritation to the parietal peritoneal wall, and is also called somatic pain

Question 4

Appendicitis

Answer 4

= inflammation of the appendix

• Infection becomes trapped in the appendix by a blockage (commonly due to a calcified ‘stone’ made of faeces). The trapped infection causes the appendix to become inflamed.

Question 5

Appendicitis

• The inflammation can quickly proceed to ________ –> ______ –> peritonitis.

Answer 5

• The inflammation can quickly proceed to gangrene –> rupture –> peritonitis.

Question 6

What is the peak age for appendicitis

Answer 6

• Peak age is 10-20 years

Question 7

Symptoms for appendicitis

Answer 7

• Abdominal pain

1. It is initially central (vague visceral pain)
2. Then it localises to the RIF (McBurney’s point) once the peritoneum is irritated (specific peritoneal pain)

• Anorexia
• Fever
• Nausea and vomiting

Question 8

Signs of Appendicitis

Answer 8

guarding,

rebound tenderness,

percussion tenderness,

Rovsing’s,

Obturator and Psoas (covered in clinical examination slide)

Question 9

During a history for suspected appendicitis you go through SOCRATES.

What are you looking for in each section to support your diagnosis

Answer 9

S – starts central, then moves to RIF

O – acute/sudden

C – deep pressure/aching = visceral peritoneum pain – sharp = parietal peritoneum/somatic pain

R – radiation to RIF or back

A – anorexia is an important feature to elicit, nausea and vomiting

T – constant

E – worse on movement

S – severe

Question 10

Appendicitis

Ix?

Answer 10

• Clinical presentation: History, Examination of abdomen
• FBC (raised WCC and raised CRP)
• Urinalysis (+ve ketones)
• Urine bHCG – for any female patient presenting with abdominal pain
Consider:
• Lactate (raised if ischaemia present)
• CT scan – useful in confirming the diagnosis if another diagnosis more likely
• USS scan – excludes ovarian or gynaecological pathology in female patients

Question 11

If the clinical presentation is suggestive of appendicitis but investigations are negative, perform a ________ ___________ (which can be converted to an appendicectomy

Answer 11

If the clinical presentation is suggestive of appendicitis but investigations are negative, perform a diagnostic laparoscopy (which can be converted to an appendicectomy

Question 12

WHat is definite management for appendicitis

Answer 12

Definitive management = laparoscopic appendicectomy

Question 13

Differentials for appendicitis?

Answer 13

• Mesenteric adenitis: Inflamed abdominal lymph nodes. Associated with tonsillitis or an URTI – look for signs on examination

• Constipation: Common in children • Elicit detailed history around bowel habits and diet

• Ectopic pregnancy: Consider in any girl of childbearing age. Urine bHCG to exclude. A gynaecological emergency

• Ovarian cysts: Can cause pelvic or IF pain, particularly with rupture or torsion

• Meckel’s diverticulum: Can become inflamed, rupture, or cause a volvulus, or intussusception

Question 14

Suspected Appendicitis

What do you look for in general inspection?

Answer 14

1. Observe the patient (appears in pain, child is not active, pallor) and around the bed (vomit bowl, analgesia)
2. Assess for peripheral stigmata (inconclusive in appendicitis) • Palpate cervical lymph nodes and look at the tonsils (an important differential is mesenteric adenitis, commonly due to tonsillitis)

Question 15

Suspected Appendicitis

WHat do you look for/do in abdomen?

Answer 15

3. Expose the abdomen (ask child or parent)
4. Palpate the abdomen (kneel, warm hands and explain to child) • Assess for guarding – suggests peritonitis • Assess for rebound tenderness (pain worse on quickly releasing pressure on RIF) – suggests peritonitis caused by a ruptured appendix
5. Percuss the abdomen • Percussion tenderness – suggests peritonitis caused by a ruptured appendix
6. Auscultate the abdomen • If absent, a surgical emergency

Question 16

What are the three signs you look out for in suspected appendicitis

Answer 16

7. Rovsing’s sign (palpation of the LIF causes pain in the RIF)
8. Psoas sign (pain on hyperextension of the right thigh with the patient lying in the left lateral position)
9. Obturator sign (pain on passive internal rotation of the flexed hip)