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Make the Diagnosis: Appendicitis, Child

Prior Probability

Every child will, at some point, experience an episode of abdominal discomfort; most do not require medical attention. If the discomfort has lasted less than 1 week and is not associated with abdominal trauma, but is severe enough to prompt a visit to the emergency department, overall about 10% of such children (age 3-18 years) have appendicitis (see Table 60-1).1

Table 60-1The Prevalence of Appendicitis in Children Varies by Age

Children for Whom Appendicitis Should Be Considered

Abdominal pain is nearly universal in appendicitis. Even though appendicitis is the most common cause of abdominal pain requiring a surgical intervention, most children will have another cause of their pain. The goal in the initial evaluation is to determine which children require an immediate surgical evaluation, which children should undergo further evaluation such as diagnostic imaging or continued observation, and which children can safely be sent home. Making the correct diagnosis promptly when preverbal children have abdominal discomfort can be difficult, as evidenced by the high appendiceal perforation rates (>80%) seen in this population.2-4

Assessing the Likelihood That a Child Has Appendicitis

See Table 60-2. In preverbal children, elicit the history from parents or caregivers with attention to their impression on how the child feels and behaviors such as eating, playing, sleeping, or stooling. The presence of right lower quadrant (RLQ) pain is a useful finding in adults, but in children RLQ pain has a summary likelihood ratio (LR) of only 1.2 (95% CI, 1.0-1.5). The presence of RLQ tenderness on the physician's examination has about the same LR as the child's report of RLQ pain, but the absence of RLQ tenderness during the clinical examination makes appendicitis less likely [summary LR, 0.45 (0.35-0.59)]. A retrocecal Appendix may create atypical pain patterns; some experts suggest that pain on deep knee squats is associated with retrocecal appendicitis.

Table 60-2Likelihood Ratios That a Child Under Evaluation in the Emergency Department for Abdominal Pain Has Appendicitis

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