Information
Appendicitis occurs when there is acute inflammation of the appendix. The inflamed appendix can then become engorged and is at risk of ischaemia and perforation. This can occur due to blockage of the appendix lumen with a faecolith or normal stool.
Clinical Features:
- Pain Migration: pain typically starts as generalised periumbilical pain but will migrate to the right iliac fossa (McBurney’s point).
- Worsening nature: the course of appendicitis is one of constant pain with duration tending to be longer than 24 hours with increasing intensity. Pain is often followed by development of associated symptoms.
- Associated Symptoms: may be associated with fever, nausea and vomiting, anorexia, diarrhoea. Percussion tenderness, and Rovsing’s sign may or may not be present (pain felt in right iliac fossa when left iliac fossa palpated)
- Children presenting with urinary symptoms can have an underlying appendicitis. Dipstick can have blood/leucocytes present but Nitrites will be negative
Differentials:
- Gastroenteritis: often main complaint is vomiting/diarrhoea above abdominal pain. Vomiting and diarrhoea may precede or occur at the same onset as pain. Pain is often diffuse rather than localised and may have a more fluctuating nature.
- Mesenteric adenitis: presents with abdominal pain that may involve a history of pain moving around abdomen e.g. may have started on the left now is in the right. A viral cause e.g. sore throat may or may not be found. Often fluctuating nature. More common than appendicitis in primary and preschool children.
- Testicular or ovarian torsion: both testicular and ovarian torsion can present with lower abdominal pain. The pain is very sudden onset, constant and severe. Always examine the testicles in boys who present with abdominal pain. See page on Testicular Torsion for more information.
- Constipation: can cause abdominal pain that is often more diffuse than localised. Lacks the systemic symptoms seen in appendicitis.
- UTI: can present with all the symptoms of appendicitis but the urine dipstick shows nitrites positive, leukocytes and blood. Always remember to examine a child’s abdomen that presents with urinary symptoms.
Who to refer:
- Any child with the above clinical features.
- Any child where the clinician has uncertainty or concerns over symptoms.
How to refer:
NHS Lothian:
- Bleep the on call paediatric surgery FY via RHCYP switchboard and send the child to RHCYP A&E. Clinical details can be discussed over the phone.
- For urgent advice call the on call paediatric surgery registrar via RHCYP switchboard.
- Please ask patients to remain fasted until they are assessed at hospital.
NHS Fife, Tayside and Borders:
- Please send to local ED and they will refer on if appropriate.
Advice to Parents:
- What to expect when arriving at the hospital – re-examination, blood tests +/- observation.
