Manejo De Sospecha En Apendicitis

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Management of suspected appendicitis in
children
J Acheson and J Banerjee
Arch Dis Child Educ Pract Ed 2010 95: 9-13

doi: 10.1136/adc.2009.168468

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B est practice

Management of suspected
appendicitis in children
J Acheson, J Banerjee
Paediatric Emergency
Department, Leicester Royal
Infirmary, Infirmary Square,
Leicester LE1 5WW, UK
Correspondence to
J Acheson, Leicester Royal
Infirmary, InfirmarySquare,
Leicester LE1 5WW, UK;
jonathan.acheson@uhl-tr.
nhs.uk
Accepted 8 September 2009

ABSTRACT
Acute appendicitis is the most important cause of
abdominal pain in children and is the commonest
that requires emergency surgery. Prompt diagnosis,
immediate referral and expeditious surgery should be
undertaken to reduce the risk of a perforated appendix.
The initial presentation may beatypical or be similar
to another pathological process which makes the
diagnosis extremely difficult. Risk assessment forms
an important part in the management of these cases.
We consider the difficulties in making the diagnosis
including: (A) the pitfalls of clinical examination; (B) the
usefulness of laboratory testing; (C) the relevance of
clinical scoring systems; and (D) the controversialissue
of imaging.
EPIDEMIOLOGY AND AETIOLOGY
Acute appendicitis in children frequently requires
emergency surgery.1 Approximately 10% of people
in the UK will develop appendicitis.2 It is more
common between the ages of 10 and 20 years but
can occur at any age. 3 T he mean age in children is
6–10 years with males more commonly affected
than females. A child younger than two usuallypresents with perforation as the diagnosis is difficult to make in this age group.
Obstruction of the appendiceal lumen is the
prime cause of appendicitis, either by a faecolith or lymphoid tissue. Intraluminal fluid accumulates leading to appendiceal distension. Poor
venous and lymphatic drainage allows bacterial
proliferation in the wall. Ischaemia and necrosis
can develop and in advanced cases theappendix
will perforate causing a generalised peritonitis.

DIFFERENTIAL DIAGNOSIS
Conditions that present with right iliac fossa (RIF)
pain include
▶ Appendicitis
▶ Acute gastroenteritis
▶ Constipation
▶ Henoch Schonlein purpura
▶ I ntussusception
▶ Lobar pneumonia
▶ Meckel’s diverticulum
▶ Mesenteric lymphadenitis
▶ M ittelschmerz
▶ Torted ovarian cyst
▶ R ight-sidedpyelonephritis
▶ Pelvic infl ammatory disease
▶ Ectopic pregnancy
Arch Dis Child Educ Pract Ed 2010;95:9–13. doi: 10.1136/adc.2009.168468

Renal calculi
Urinary tract infection
Gastroenteritis is a common cause of abdominal pain in children. Symptoms include vomiting, diarrhoea and fever. Rotavirus, adenovirus,
enterovirus and Norwalk virus are the most common causes. Examination may revealgeneralised
tenderness, increased bowel sounds and signs of
dehydration.
Constipation can present with severe abdominal pain and maybe recurrent. The pain is most
often left sided or suprapubic. Firm stool maybe
palpable in the lower abdomen.
Henoch Schonlein purpura is often preceded by
a painful throat or respiratory tract infection. The
abdominal pain can be severe in nature. The classical...