Most common nontraumatic condition requiring emergency abdominal surgery in children and adolescents

Missed appendicitis or delays to diagnosis are among the common scenarios resulting in a complaint or lawsuit regarding ED care

May present at any age, but most common in second and third decades (peak incidence 9-12 years)

˜1 in 15 lifetime risk of developing appendicitis

M:F ratio is 2:1

Incidence of perforation at diagnosis is highest in children < 1 yr (almost 100%), 94% < 2 yrs, and 60-65% < 6 yrs

Mortality rate 0.1% (nonperforated), 3-5% (perforated)

Young children can progress to perforation rapidly within 6-12 hrs from symptom onset

Need a high index of suspicion

Lumen of the appendix vermiformis becomes obstructed

Less likely in infants due to primitive shape and relative lack of lymphoid tissue in appendix

Obstruction commonly caused by

Obstruction leads to venous engorgement, inflammation, and eventual necrosis and perforation

In adolescents and adults, omentum may help to “wall-off” appendicitis

Omentum less developed in young children, leading to a higher likelihood of diffuse peritonitis and increased morbidity and mortality

Classic symptoms: abdominal pain, low-grade fever, and vomiting

Abdominal pain

Anorexia and nonbilious emesis

Some degree of fever is often present

In many cases, atypical symptoms may occur and lead to misdiagnosis

Urinary frequency and dysuria if inflamed appendix is close to the ureter and bladder

Diarrhea (frequent, small volume, and loose stools) and tenesmus (fecal urgency) may occur in retrocecal appendicitis or if appendix is near a segment of colon

Resting tachycardia or fever may not be universally present, particularly in nonperforated appendicitis

May walk with slightly hunched-over gait or prefer to lie still

Pain increases with movement

Early, generalized abdominal tenderness with soft abdomen

Later: pain may localize to RLQ, maximally tender at McBurney’s point

Pain may be increased with palpation or percussion over descending colon (Rovsing’s sign)

Rebound tenderness on light palpation and involuntary guarding of the right lower quadrant may be present

Positive iliopsoas or obturator signs suggest retrocecal appendicitis:

Digital rectal examination of limited value, may be helpful if equivocal or difficult abdominal examination (i.e., obese
patient) or in female adolescents to help to differentiate appendicitis from pelvic pathology