Psoas sign (RIF pain on hyperextension of the right hip)
Obturator sign (RIF pain on internal rotation of the flexed right hip)
These signs are more relevant in older children
The typical picture in the infant is the septic appearing child who has generalised abdominal tenderness
If generalised peritonitis develops, then guarding and rebound tenderness also becomes generalised
An inflamed appendix adjacent to the urinary bladder or a ureter may give rise to irritative urinary symptoms, pyuria and haematuria
Vomiting which precedes abdominal pain is unlikely to be due to appendicitis
Non-abdominal features of the examination – such as ability to hop, move around, climb onto the trolley undistressed may help to support or refute the likelihood of appendicitis
In all cases where appendicitis is suspected, a urine should be checked to exclude urinary tract infections
Remember that appendicitis, as well as fever itself may give rise to mild pyuria or haematuria
These should only be done in cases where diagnosis is uncertain and if they will change management and can include:
Abdominal X-Ray: is unhelpful in diagnosing appendicitis. It does have a place however in cases where perforation or generalised peritonitis are suspected. Look for RIF air-fluid levels or faecolith.
U&E: These should only be checked if the child has had profuse vomiting and is thought to be dehydrated. Electrolyte abnormalities and dehydration need to be corrected before surgery.
Ultrasound / CT: These modalities are increasingly being used to aid in the diagnosis of appendicitis, and are helpful in excluding other causes of abdominal pain. They should only be ordered on the request of the surgeon or Senior ED Doctor, following his/her assessment of the patient.
FBC / CRP: Literature is inconsistent as to the WBC parameters in children with appendicitis. Although a raised WCC / CRP suggests infection, it is neither sensitive nor specific for appendicitis.
Keep patient NBM (insert a nasogastric tube (NGT) if vomiting is continuous)
If shocked, resuscitate:
Insert IV cannula
Bloods: FBC, U&E, Group and Hold
IV fluid bolus 0.9% saline – 20mL/kg and repeat if required
Electrolytes: Correct significant abnormalities if indicated
Analgesia: Usually IV morphine is required. See ED Guideline – Analgesia.
Antibiotics: IV antibiotics may be requested by the General Surgical Team. Use Piperacillin/Tazobactam 100mg/kg (maximum dose 4g piperacillin). See ED Guideline – Antibiotics.
If the diagnosis is uncertain:
In some cases where a clinical diagnosis of appendicitis could not be made or definitely excluded, the child should have a review by the General Surgical Team
Some of these children will need to be admitted under a surgeon and observed for a period of 12-24 hours in a centre where surgery can be performed
During this observation period they may be kept nil by mouth, given appropriate IV fluids and adequate analgesia, and have regular abdominal examinations
In children with non-localising signs or very recent onset of symptoms (unlikely appendicitis), it may be reasonable to discharge the child home with clear instructions for parents to represent to the Emergency Department if the symptoms progress
Keep patient nil by mouth (NBM) until advised otherwise by the General Surgical Team
Apply EMLA cream (but if unwell IV cannula may be inserted immediately)