Acute Appendicitis in Pediatric Patients: An Evidence-Based Review

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Points and Pearls Excerpt

• Studies in adults with appendicitis show that abdominal pain almost always precedes vomiting. This typical sequence is less common in preschool-aged children; they can present with vomiting that precedes abdominal pain.
• Fever is the most suggestive sign of appendicitis in patients with undifferentiated abdominal pain. Rovsing sign is the examination finding that is most suggestive of acute appendicitis. Other signs include cough/hop pain and right iliac fossa tenderness.
• Basilar pneumonia should be considered for all children presenting with abdominal pain.
• Consider ordering a pelvic ultrasound for girls of childbearing age, as pelvic pathology can be confused with appendicitis.

Most Important References

• Kharbanda AB, Vazquez-Benitez G, Ballard DW, et al. Development and validation of a novel pediatric appendicitis risk calculator (pARC). Pediatrics. 2018;141(4). (Prospective; 3849 patients)
• Schneider C, Kharbanda A, Bachur R. Evaluating appendicitis scoring systems using a prospective pediatric cohort. Ann Emerg Med. 2007;49(6):778-784. (Prospective; 588 patients)
• 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.e362. (Review article)
• Schuh S, Man C, Cheng A, et al. Predictors of non-diagnostic ultrasound scanning in children with suspected appendicitis. J Pediatr. 2011;158(1):112-118. (Prospective; 263 patients)
• Partain KN, Patel A, Travers C, et al. Secondary signs may improve the diagnostic accuracy of equivocal ultrasounds for suspected appendicitis in children. J Pediatr Surg. 2016;51(10):1655-1660. (Retrospective; 825 patients)