Paeds · gastroenterology-hepatology-and-nutrition
Appendicitis and surgical abdomen
Also known as Acute appendicitis · Pediatric appendicitis score · Migratory right iliac fossa pain · McBurney point tenderness · Perforated appendicitis · Appendiceal mass · Laparoscopic appendicectomy · Non-operative appendicitis · Surgical abdomen · Fecolith
Fellowship guide to appendicitis as the paradigm of the paediatric surgical abdomen, built around the child with periumbilical pain that migrates to the right iliac fossa with anorexia, nausea and localised tenderness. The page covers the obstruct-ischaemia-perforate pathophysiology, the ten-point Pediatric Appendicitis Score, ultrasound as first-line imaging with magnetic resonance imaging as the radiation-sparing second line, resuscitation and analgesia that never delay diagnosis, laparoscopic appendicectomy as the standard against the evolving non-operative antibiotic option chosen by shared decision, and the recognition of the sick surgical abdomen in which a bilious vomit, guarding, a rigid abdomen or a torsed testis must never be missed.
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Red flags
- A child with periumbilical pain that migrates to the right iliac fossa with anorexia, nausea and localised tenderness has appendicitis until proven otherwise, and a genuinely hungry child rarely has it
- A bilious vomit in a child with abdominal pain is malrotation with midgut volvulus until imaging proves otherwise and is a surgical emergency, not a reassuring sign
- Peritonitis with guarding, rigidity, a rigid abdomen or shock signals a perforated or ischaemic viscus and converts the plan straight to resuscitation, antibiotics and the operating theatre
- Every boy with apparent abdominal pain must have the testes examined, because testicular torsion presents as lower abdominal pain and is salvaged by detorsion within six hours
- Appendicitis in a child under five is typically perforated at presentation because the history is short and atypical, so a tender irritable toddler deserves a low threshold for imaging and surgery
Life stages
Care settings
Clinical exam formats
Board mappings
- Appendicitis as the commonest surgical emergency of the childhood abdomen
- Migratory pain, anorexia and right iliac fossa tenderness
- Principles of resuscitation and analgesia before surgery
- Pediatric Appendicitis Score and the ultrasound-first imaging pathway
- Non-operative antibiotics versus laparoscopic appendicectomy and shared decision
- Appendiceal mass and abscess, interval appendicectomy and perforated appendicitis
- The school-aged child with migratory right iliac fossa pain
- Interpreting the abdominal ultrasound and the appendicitis score
- Fluid resuscitation and opioid analgesia in the child with an acute abdomen
- Short case: abdominal examination of the child with localised tenderness
- Long case: non-operative appendicitis and the shared-decision conversation
- Gastroenterology and surgery: appendicitis and the acute abdomen in children
- Acute abdominal pain and recognising the surgical abdomen
- Appendicitis: presentation, the appendicitis score and the imaging pathway
- Non-operative management and the recognition of perforation and peritonitis
- Assessment of the child with migratory abdominal pain and anorexia
- Acute appendicitis
- The acute surgical abdomen in children
- Non-operative management and laparoscopic appendicectomy
- Patient Care: recognition, stabilisation and surgical referral of appendicitis
- Medical Expert: appendicitis and the surgical abdomen in children
Overview & Definition
Picture an eight-year-old who felt vaguely off at breakfast, refused his cereal, and by evening is curled on the sofa pointing to a sore spot just inside his right hip bone. That arc, from a vague central ache to a sharp, localised right iliac fossa pain with loss of appetite, is the signature of acute appendicitis. It is the commonest abdominal surgical emergency of childhood, and the condition that defines what examiners call the surgical abdomen: a child whose pain signals a problem that an operation, not a prescription, will solve. [3] [4]
The danger unfolds in two ways. Locally, the obstructed appendix swells, becomes ischaemic and may perforate, spilling pus to cause peritonitis or a walled-off abscess. Systemically, a missed surgical abdomen such as a midgut volvulus, an incarcerated hernia or a torsed testis can cost bowel or a gonad within hours, which is why the discipline of the acute abdomen is to recognise the surgical patient first and name the diagnosis second. The art is to act on the migratory pain and the tenderness before the perforation arrives. [3] [1]
The governing principle is therefore recognition coupled with a graded response. You assess and resuscitate, apply the Pediatric Appendicitis Score to stratify risk, image with ultrasound first and reserve second-line magnetic resonance imaging or computed tomography for the equivocal case, and then choose between laparoscopic appendicectomy and, for selected uncomplicated cases, non-operative antibiotics through shared decision. Most children do well, which is exactly why catching the pattern early matters. [3] [6]
References12ShowHide
- [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
- [4]Addiss DG; Shaffer N; Fowler BS; et al The epidemiology of appendicitis and appendectomy in the United States. Am J Epidemiol, 1990.PMID 2239906
- [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
- [7]Minneci PC; Hade EM; Gil LA; et al Demographic and Clinical Characteristics Associated With the Failure of Nonoperative Management of Uncomplicated Appendicitis in Children: Secondary Analysis of a Nonrandomized Clinical Trial. JAMA Netw Open, 2022.PMID 35499827
- [8]Minneci PC; Cooper JN; Leonhart K; et al Effects of a Patient Activation Tool on Decision Making Between Surgery and Nonoperative Management for Pediatric Appendicitis: A Randomized Clinical Trial. JAMA Netw Open, 2019.PMID 31173118
- [9]Pátková B; Svenningsson A; Almström M; et al Long-Term Outcome of Nonoperative Treatment of Appendicitis. JAMA Surg, 2023.PMID 37556160
- [10]van Amstel P; Sluckin TC; van Amstel T; et al Management of appendiceal mass and abscess in children; early appendectomy or initial non-operative treatment? A systematic review and meta-analysis. Surg Endosc, 2020.PMID 32710216
- [11]Wang CH; Yang CC; Hsu WT; et al Optimal initial antibiotic regimen for the treatment of acute appendicitis: a systematic review and network meta-analysis with surgical intervention as the common comparator. J Antimicrob Chemother, 2021.PMID 33792691
- [12]Cramm SL; Graham DA; Blakely ML; et al Postoperative Antibiotics, Outcomes, and Resource Use in Children With Gangrenous Appendicitis. JAMA Surg, 2024.PMID 38324276