Paeds Cases · gastroenterology-hepatology-and-nutrition
Appendicitis and surgical abdomen — structured clinical encounter
Structured encounter testing the approach to a previously well nine-year-old with migratory right iliac fossa pain, anorexia and localised tenderness: the recognition of the migratory pattern and the anorexia clue, the exclusion of the surgical mimics including testicular torsion, the Pediatric Appendicitis Score and the ultrasound-first imaging pathway, resuscitation and analgesia that do not delay diagnosis, laparoscopic appendicectomy against the non-operative option by shared decision, and the safety-netting and recurrence conversation with the family.
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Station 1 — assessment and recognition
Asked for my first impression, I explain that a previously well nine-year-old with peri-umbilical pain that has migrated to the right iliac fossa over eighteen hours, with anorexia, nausea and localised tenderness at McBurney point with a wince on hopping, has the classic sequence of acute appendicitis. I would ask him to point with one finger to where it hurts most, watch him hop or cough to elicit the peritoneal wince, and grade him as mildly dehydrated from the reduced intake and vomiting. [1]
References6ShowHide
- [1]Samuel M Pediatric appendicitis score. J Pediatr Surg, 2002.PMID 12037754
- [2]Bhatt M; Joseph L; Ducharme FM; et al Prospective validation of the pediatric appendicitis score in a Canadian pediatric emergency department. Acad Emerg Med, 2009.PMID 19549016
- [3]Bhangu A; Søreide K; Di Saverio S; et al Acute appendicitis: modern understanding of pathogenesis, diagnosis, and management. Lancet, 2015.PMID 26460662
- [5]Salminen P; Paajanen H; Rautio T; et al Antibiotic Therapy vs Appendectomy for Treatment of Uncomplicated Acute Appendicitis: The APPAC Randomized Clinical Trial. JAMA, 2015.PMID 26080338
- [6]Eng KA; Abadeh A; Ligocki C; et al Acute Appendicitis: A Meta-Analysis of the Diagnostic Accuracy of US, CT, and MRI as Second-Line Imaging Tests after an Initial US. Radiology, 2018.PMID 29916776
- [9]Pátková B; Svenningsson A; Almström M; et al Long-Term Outcome of Nonoperative Treatment of Appendicitis. JAMA Surg, 2023.PMID 37556160