General Surgery Emergencies

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CHAPTER 44 General Surgery Emergencies

Kristine G. Williams, MD, MPH, Dee Hodge, III, MD

1 What is the classic presenting history in a child with suspected appendicitis?

Usually the child presents with a history of diffuse abdominal pain, possibly associated with vomiting and a low-grade fever. Some may have a history of anorexia. Unlike in adults, it is often hard to obtain an accurate and consistent history. The presenting symptoms of appendicitis are similar to those of many other childhood diseases. Gastroenteritis, urinary tract infections, streptococcal pharyngitis, constipation, and pneumonia are just a few of the illnesses that appendicitis can mimic. Most children with appendicitis complain of pain in the right lower quadrant (RLQ) once peritoneal inflammation occurs.

Bachur RG: Abdominal emergencies. In Fleisher GR, Ludwig S, Henretig FM (eds): Textbook of Pediatric Emergency Medicine, 5th ed. Philadelphia, Lippincott Williams & Wilkins, 2006, pp 1605–1630.

eMedicine: General surgery articles: www.emedicine.com/ped/GENERAL_SURGERY.htm

2 Where else might a child with appendicitis localize pain?

If the appendix is located in the lateral gutter, the child may exhibit tenderness in the lateral abdomen or flank. An appendix pointing toward the pelvis might cause pubic pain and diarrhea. A retrocecal appendix causes pain on deep palpation. This information is important, since not all children with appendicitis present with RLQ pain.

3 Is diarrhea a presenting symptom of appendicitis?

Yes. Diarrhea may delay accurate diagnosis if the symptom is mistakenly associated with gastroenteritis rather than appendicitis. Children under 3 years old are the ones most likely to present with this symptom. A retrospective case series identified 63 children under the age of 3 who had an appendectomy for appendicitis at one of four teaching institutions. The mean age was 2.2 years. The mean delay from the onset of symptoms to presentation was 4.3 days, and 57% were misdiagnosed at initial presentation! Diarrhea was reported in one third of the patients. Although none of the children died, morbidity was increased: 84% had perforation or gangrene.

Serious and life-threatening disease processes must be kept in mind when a young child presents with symptoms that may look like simple gastroenteritis.

Horwitz JR, Gursoy M, Jaksic R, Lally KP: Importance of diarrhea as a presenting symptom of appendicitis in very young children. Am J Surg 173:80–82, 1997.

4 Does a white blood cell (WBC) count of only 11.5 cells/mm3 rule out appendicitis?

A child with a nonperforated appendicitis usually has a WBC count of 11,000–15,000 cells/mm3 in the first 1–2 days of illness. A higher WBC count with a left shift may be found later in the course, as the appendix undergoes further degeneration, or if the appendix has ruptured. Although laboratory values may help to support your clinical diagnosis, they should not replace a good history and a careful physical examination.

5 What laboratory findings are suggestive of appendicitis?

The two tests that should be done on all patients who are suspected of having appendicitis are a complete blood count with differential and a urinalysis. WBC counts appear to be highly associated with both uncomplicated acute and complicated acute appendicitis, and are a good tool to aid in diagnosis. The urinalysis may show ketosis due to decreased oral intake. If the inflamed appendix lies near the bladder or ureter, sterile pyuria may be seen as well. However, a normal complete blood count or a normal urinalysis do not rule out appendicitis.

6 Is C-reactive protein (CRP) helpful in diagnosing appendicitis?

Greatly elevated CRP levels (e.g., > 50 mg/L) have been found to be associated with perforated appendicitis. A patient with a normal WBC count AND a normal CRP level is unlikely to have appendicitis. Here is the evidence: Investigators have examined the use of CRP and WBC values to predict appendicitis at different stages. In one retrospective study, 100 adult and pediatric patients in each of the following categories had mean preoperative values calculated: uninflamed appendix, uncomplicated acute appendicitis, and complicated acute appendicitis. Although some of the patients with uninflamed appendices had increased WBC or CRP values, all patients with both values in the normal range had an uninflamed appendix. Those with uncomplicated acute appendicitis had either raised WBC counts and normal CRP levels, or elevated values of both. Most of those with complicated acute appendicitis had both values raised. A prospective study of pediatric patients with appendicitis showed a positive predictive value of 91% for perforation if the CRP level was > 50 mg/L. There was no difference in WBC counts among those with and without perforation.

Chung JL, Kong MS, Lin SL, et al: Diagnostic value of C-reactive protein in children with perforated appendicitis. Eur J Pediatr 155:529–531, 1996.

Gronoos JM, Gronoos P: Leukocyte count and C-reactive protein in the diagnosis of acute appendicitis. Br J Surg 86:501–504, 1999.

7 Is a plain x-ray useful in diagnosing appendicitis?

Plain radiography is not very helpful. It usually reveals nonspecific findings for appendicitis, unless a calcified appendicolith is present (< 10% of patients). The presence of air–fluid levels in the RLQ suggests a localized ileus. Although this finding may heighten one’s suspicion for appendicitis, beware! The same findings are also present in gastroenteritis. Plain films may reveal an alternate diagnosis, such as pneumonia.

Heller RM, Hernanz-Schulman M: Applications of new imaging modalities to the evaluation of common pediatric conditions. J Pediatr 135:632–639, 1999.

8 Is ultrasonography useful in evaluating for appendicitis?

Ultrasonography has a reported sensitivity of approximately 80% and a reported specificity of approximately 93% for the diagnosis of appendicitis. It is quick and does not involve large doses of radiation. It can identify ovarian pathology, such as ovarian cysts or torsion. However, there are limitations to this technology:

image It requires an experienced technician.

image It is difficult to scan overweight children.

image It is uncomfortable for the patient because of a need for graded compression of overlying bowel.

image It can be extremely difficult to perform on a crying or uncooperative child.

image The appendix can be located anywhere in the abdomen, making visualization difficult at times. If visualized, the inflammation may be localized to a small segment that cannot be seen.

Thus, a positive result is highly suggestive, but a negative result should be followed with repeated physical examination and reassessment of your level of suspicion for the diagnosis. If the appendix cannot be visualized, appendicitis is not ruled out.

9 What is the value of computed tomography (CT) in diagnosing appendicitis?

CT is a valuable modality for appendicitis. It has a sensitivity of about 95% and a specificity of about 93% for the diagnosis of appendicitis. Of course, there are drawbacks to CT as well. The need for contrast material, exposure to radiation, higher cost, and a longer preparatory period prior to the study are a few of them. Although some patients with a suspected inflamed appendix may not need imaging, the most sensitive imaging modality is abdominal CT.

Sivit CJ, Applegate KE, Stallion A, et al: Imaging evaluation of suspected appendicitis in a pediatric population: Effectiveness of sonography versus CT. AJR 175:977–980, 2000.

10 What is focused CT of the abdomen?

Focused CT of the lower abdomen, beginning at the lower end of the third lumbar vertebral body and extending to the pubic ramus, may effectively diagnose appendicitis. It offers a lower dose of radiation and is therefore a good option in the diagnosis of appendicitis.

Fefferman NR, Roche KJ, Pinkney LP, et al: Suspected appendicitis in children: Focused CT technique for evaluation. Radiology 220:691–695, 2001.

11 Why does the pain of appendicitis typically start centrally (periumbilically) and then localize to the right lower quadrant?

The initial pain of appendicitis is visceral: a dull, aching pain localized to the mid- or lower abdomen. Visceral or splanchnic pain originates in those abdominal organs, such as the appendix, that have visceral peritoneum. Increased hollow viscous wall tension and ischemia cause impulses to be sent from the organ to the spinal cord. In the case of the appendix, visceral afferent autonomic nerves enter the spinal cord at T8–T10. These segments supply the periumbilical area, which explains the initial, poorly localized pain associated with appendicitis.

As the appendix becomes more inflamed, it causes inflammation of the serosa and parietal peritoneum. The inflammation triggers local somatic pain fibers. Somatic pain is mediated by afferent nerve fibers in segmental spinal nerves. Thus, the pain is sharper and more localized, usually to the RLQ.

12 Describe the pathophysiologic mechanism that leads to appendicitis.

The appendix contains increasing amounts of lymphatic tissue as a child ages. Acute appendicitis occurs when the lumen of the appendix becomes obstructed. Sources of obstruction include fecaliths, lymphatic hypertrophy, worms, vegetable matter, and tumors. The appendix continues to secrete mucosal fluid, leading to distention of the viscus. Intraluminal bacterial overgrowth develops.

KEY POINTS: COMMON FINDINGS IN ACUTE APPENDICITIS

1 Diffuse or periumbilical abdominal pain

2 Low-grade fever

3 Vomiting or diarrhea

4 Anorexia

13 Which of these patients with appendicitis is most likely to present with a perforation? Why?

A A 2-year-old boy with pain for a few days

B A 12-year-old girl with severe pain for 24 hours

C An 8-year-old boy with a temperature of 40° C

D A 16-year-old with a WBC count of 18,000 cells/mm3

Although any one of the patients could present with a perforated appendix, the 2-year-old with pain for 2 days is statistically most likely to have perforation at presentation. The rates of perforation are higher in younger children because of the following several factors: (1) the appendix is more thin walled, predisposing them to early perforation; (2) younger children are less able to communicate clearly, resulting in prolonged symptoms before diagnosis; and (3) the level of suspicion for appendicitis is often lower in younger age groups, leading to a delay in diagnosis.

14 Why does perforated appendicitis progress to peritonitis more quickly in infants and children than in adults?

The omentum is not as well developed in infants and children as it is in adults. Since the omentum is primarily responsible for walling off the infection in a perforated appendicitis, its insufficiency contributes to the development of peritonitis. This complication of perforated appendicitis may play a role in the increased mortality in young children with appendicitis.

15 What conditions must be considered in a teenage girl with symptoms of appendicitis?

Gynecologic conditions and emergencies should be a part of the differential diagnosis of any teenage girl with RLQ pain. In particular, ovarian cysts, corpus luteal cysts, mittelschmerz, tubal pregnancy, ovarian torsion, tubo ovarian abscess, and salpingitis can all present similarly to appendicitis.

16 What is the most common cause of acute pancreatitis in children?

Abdominal trauma.

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