Apendicitis
                                 ===========
þ Evaluating for appy in kids
Brundy, et al. Does this child have appendicitis? JAMA.
2007;298(4):438-451
- Accuracy of Symptoms
1. Abdominal Pain: selection criteria … so all had it
2. Length of symptoms (24 hours): no difference
3. RLQ pain:
a. Positive LR: 1.2 (minimal impact)
b. Absence: LR: 0.56
4. Migration
a. Positive LR: 1.9 - 3.1
b. Absence: LR: 0.4 - 0.7
5. Fever: variable definitions (37 - 38.1)
a. Positive:
i. Level 1 study: LR 3.4, Level 3 studies: no help
b. Absence
i. Level 1 study: LR: 0.32, Level 3 studies: 0.53
6. Vomiting and Diarrhea
a. Positive: Level 1 study: LR 2.2, Level 3 studies: not helpful
b. Absence of vomiting: LR 0.57 across all studies
c. Absence of diarrhea: no help
D. Accuracy of Signs
1. Localized abdominal tenderness: not helpful
2. RLQ tenderness
a. Present: not helpful
b. Absent: LR 0.45 (about the same as absence of symptom)
3. Rebound: evaluated in three studies
a. Present: LR: 3.0
b. Absent: LR: 0.28
4. Involuntary Guarding: 2 studies (about the same as Rebound)
a. Present: LR: 1.6 - 2.6
b. Absent: LR: 0.21 - 0.61
5. Rectal Tenderness
a. Present: LR: 2.3
b. Absent: not helpful
6. Psoas sign
a. Present: LR 2.0 - 2.5
b. Absent: not helpful
E. Accuracy of Lab Tests
1. WBC
a. Present >10K: LR: 2
b. Absent (<10K): LR: 0.22
i. One study: <8850: LR: 0.06
2. C-reactive Protein and ESR: inconsistent
F. Accuracy of Symptom-Sign Combinations
1. Alvarado/MANTRELS (Score >7): 3 studies
a. Present: LR: 4
b. Absent (<7): LR: 0.2
c. Modified Alvarado (no L) about the same
VI. Comparison to Adult appendicitis
A. RLQ pain is a stronger predictor in adults
B. Fever, anorexia, N/V are poor predictors in adults and kids
C. Rebound and psoas sign same for both

þ Appendicitis Etiology and Natural History:
 - thought to be obstruction by a fecalith
 - Classical Presentation: periumbilical pain and anorexia, followed by
   vomiting and right lower quadrant pain -- seen about 60% of the time.
 - sometimes, after perforation, a piece of omentum will wall off the area,
   forming an abscess; otherwise, generalized peritonitis results.
 - pertonitis more likely in young children due to less omentum

þ Appendicitis in Pediatrics
  - CT with standard adult protocol appropiate and useful [Sivit CJ et al.
    Evaluation of suspected appendicitis and young adults: helical CT. Radiology
    2000 Aug;216(2):430-3]
  - Children with appendicitis twice as likely to have + FH than surgical
    controls without abdominal pain.  [Gauderer MW et al. Acute appendicitis
    in children: the importance of family history. J Pediatr Surg 2001
    Aug;36(8):1214-7.]

þ Physical Exam and Testing for Appendicitis
  <AppyTest.TXT>

þ Causes of "pseudo-appendicitis"
  <PseuAppy.TXT>

þ Acceptable used to be 20% false positive in OR

þ Role of antibiotics in appendicitis:
 - "Most clinicians do administer broad-spectrum antibiotics in
   these patients. The antibiotics are usually stopped after
   surgery if there is no perforation."
   [emedicine.com - http://www.emedicine.com/emerg/topic361.htm
   (Tucker [au] and Bechtel [ed])]